Introduction by Croakey: In a recent media article, Health Minister Mark Butler stressed the importance of reforms to the Pharmaceutical Benefits Scheme to ensure “affordable, reliable access to medicines for all Australians”.
Access to medicines drives both equity and economic strength, he said.
“When medicines are more effective and more affordable, people can manage their conditions and stay engaged in work. And when people stay in work, they contribute to a stronger, more resilient economy. We don’t say this often enough: medicines policy is economic policy,” he said.
However, medicines also cause considerable harm. One study estimated that at least 250,000 hospital admissions annually in Australia are medication-related, with an estimated cost of $1.4 billion. Two-thirds of these admissions are potentially preventable, the researchers found.
Home Medicines Reviews (HMR) are an important strategy for maximising the benefits and minimising the harms from medications, especially for people taking multiple treatments.
However, caps on the number of HMRs that can be undertaken by credentialed pharmacists are undermining patient care, and also contributing to moral injury for health professionals like Kelly Abbott.
“In the past, I have telephoned to book in a visit delayed by the cap and have been told that the person had already passed away. This haunts me,” Abbott writes below.
She invites Minister Butler to spend a day with her at work in Victoria’s Latrobe Valley so he can develop a first-hand appreciation for the service. Also watch her video report.
Kelly Abbott writes:
Credentialed pharmacists are a rare breed; there are approximately 4,000 pharmacists qualified to practise at this level across Australia, performing advanced medication management services for Australians in need of medication safety services.
As one of only four credentialed pharmacists living and working in Australia’s unhealthiest region, the Latrobe Valley in Victoria, you would imagine I’d be busy doing Home Medicines Reviews (HMRs) every day.
Yet, as I write this article, I’m cosy at home on a Friday in mid-June, with a long list of patients who won’t be seen until mid-July. This is not unusual for me; I have many days in every month where I could be supporting medication safety in my community through HMRs but instead I’m at home.
Towards the end of every month, many credentialed pharmacists across Australia are like me and cannot visit people for a HMR despite their GP asking for one, in some cases ASAP.
We are shackled by an illogical cap that limits us to only providing 30 Federal Government-funded HMRs per month per pharmacist. Many credentialed pharmacists are willing and able to see more Australians in need of our help, but the Government simply will not pay us to.
In May, I received 59 referrals from local GPs for patients with chronic medical conditions that the GP believes would benefit from a home visit from a credentialed pharmacist. I’m forced to delay around half of these people’s reviews due to the cap or ask them to pay privately to jump the queue.
I actively share referrals with colleagues nearby and those further afield, but they too are capped or preferentially do other, better-remunerated work.
June saw another 43 referrals arrive, which means the waiting list for my help lengthens by another 13 people.
The cruelty I am forced to inflict by triaging people based on their on-paper referral negatively impacts my wellbeing each month. I worry that by my having to choose who receives my healthcare and who is delayed, I will miss seeing someone at a critical time where my visit could keep them out of hospital or even keep them alive.
In the past, I have telephoned to book in a visit delayed by the cap and have been told that the person had already passed away. This haunts me. It is unnecessary.
I have the capacity to visit at least 60 people per month and hence double my impact on reducing hospitalisation, polypharmacy, medication errors, adverse reactions and harmful drug interactions.
If a referral marked ‘urgent’ arrives, it’s heartless to ask someone else already booked to wait even longer to enable me to see this new person.
Many people I visit in their homes marvel at this ‘new service’, unaware that it has existed since 2001. But with many credentialed pharmacists ‘capped out’, there is no point in us raising the profile of the service when we cannot even meet current demand.
I often explain to patients that the wait to see me is simply due to the cap. Not one person has ever told me that it makes sense; they are incredulous to find a service such as this rationed despite their GP requesting it and desiring the credentialed pharmacist’s input.
Can you imagine walking into your dentist with a freshly broken tooth and being told that even though the only dentist in town is available, you have to come back on 1 July because they have treated their allowed 30 patients this month? If you want that tooth fixed, either you pay privately to jump the monthly queue or you wait in pain.
While the Government is encouraging less expensive medicines and incentivising bulk-billing at GP practices, it is actively promoting the exact opposite on medication safety services.
There is no limit on how many patients a GP can refer for a HMR per month; this is a good thing as referral should be based on clinical need. But when credentialed pharmacists are limited, this creates a bottleneck, especially in those areas of Australia where there are not enough of us to meet demand.
The result is that thousands of Australians remain at risk of medication misadventure longer than they should.
It’s not simply GPs who appreciate the benefits of Home Medicines Reviews. A publication released recently identifying priorities for improving asthma care, ‘A Bold Blueprint for Asthma Reform in Australia’, recommended healthcare providers “offer every patient with asthma the opportunity for a Home Medicines Review (HMR) via GP referral”.
This amounts to an estimated 2.8 million Australians living with asthma needing to be seen by Australia’s 3,000 credentialed pharmacists. The caps mean 2.5 years would pass before every person with asthma could be seen, assuming these pharmacists worked to their full cap and only saw people with an asthma diagnosis.
The Pharmaceutical Society of Australia (PSA) is leading an UncapCare campaign to address a range of issues beyond the cap that relate to medication safety services in settings beyond the four walls of a pharmacy.
Remuneration for credentialed pharmacists has been frozen since 2019, meaning we have absorbed a 30 percent pay cut whilst caring for vulnerable Australians. On top of this freeze, travel funding is available only for extremely long journeys and there a flat fee, irrespective of clinical complexity.
This situation means credentialed pharmacists are financially disadvantaged if we see patients with complex medicine needs and those in rural and remote areas – those who often need our services most.
The Government signed a Heads of Agreement with the PSA to address these issues but the recent Federal Budget brought only disappointment for credentialed pharmacists and our patients.
The Government argues that “the monthly cap helps ensure the HMR program is sustainable and allows each pharmacist to deliver reviews for the patients who need them most, in their homes”.
The weaknesses in this statement are vast. The HMR service requires a GP referral for a pharmacist to perform the review; are they suggesting that GPs are over-referring? Hardly; I’ve had many GP tell me that they’ve held back on referring someone who is in need of an HMR because they know I have a long waiting list due to the cap.
A GP clinic situated an hour’s drive from my home has begged me twice in recent years to come and visit their patients because they have no credentialed pharmacist nearby. That’s the largest clinic in a town of nearly 6,000 people who are not able to refer their patients to a service their GP believes would benefit them – purely due to the Government’s inflexibility regarding the HMR program rules.
In an aging population with increasing clinical complexity and escalating medication burdens, and with Medication Safety as a National Health Priority, it is staggering that the Federal Government appear unwavering in their determination to limit medication safety services.
In my rural region, as in most others, clinical skills like mine are in high demand due to a shortage of credentialed pharmacists but it’s the locals who are suffering because their HMR is delayed.
The Federal Health Minister, Mark Butler, could change this situation for myself and, more importantly, for my community by adequately funding Home Medicines Reviews.
Minister Butler, I’d be delighted to welcome you to the Latrobe Valley to ride along with me for a day, visiting my beloved locals in their homes to see the value of this service and how important it is for you to increase access for Australians to the benefits of credentialed pharmacists.
Previously at Croakey: Key patient safety initiative needs urgent attention from the Federal Government
Author details
Kelly Abbott is a credentialed consultant pharmacist based in Traralgon, Victoria, with a portfolio career spanning credentialed medication management reviews, quality use of medicines services in aged care and GP education. She is also the pharmacist on the Heart Failure Multidisciplinary Team at Royal Medical Centre in Morwell. She advocates strongly for the expansion of the Home Medication Review program and this year was named the PSA/MIMS Consultant Pharmacist of the Year. She has previously taught pharmacology to medical students at Monash University, Churchill, worked for Gippsland PHN in digital health, performed assessment for the Pharmaceutical Society of Australia and for Monash University, Parkville and practised pharmacy in hospital and community settings in Gippsland. She is currently studying the Doctor of Pharmacy Practice at the University of Western Australia.
Watch the video report
See Croakey’s archive of articles on safety and quality of healthcare
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