Introduction by Croakey: Sweeping recommendations aimed at ensuring community pharmacies deliver better care for patients, and better value for taxpayers have been put forward by the Grattan Institute.
The Institute’s new report, Future Pharmacy: A better deal for patients and taxpayers, has called for an end to Community Pharmacy Agreements (currently negotiated between the Federal Government and the powerful Pharmacy Guild of Australia), and for the Independent Health and Aged Care Pricing Authority (IHACPA) to be made responsible for determining pharmacy remuneration.
If the Federal Government will not end the Community Pharmacy Agreements, the report says it should include pharmacists and patients in the agreements, and base them on public evidence.
The report calls for simpler and fairer dispensing fees, an end to unjustified protection for pharmacy owners, and for the Government to direct the Australian Competition and Consumer Commission (ACCC) to do a market study of the community pharmacy sector and design appropriate safeguards to protect competition.
It also recommends funding for pharmacist prescribing for urinary tract infections, and funding of rigorous national trials of pharmacist prescribing for other minor ailments, smoking cessation, and collaborative chronic disease management.
And the Government is urged to invest $80 million in integrating non-dispensing pharmacists into general practice, via commissioning by Primary Health Networks, and in Aboriginal Community Controlled Health Services (ACCHSs), via commissioning by the National Aboriginal Community Controlled Health Organisation (NACCHO).
This funding could support about one in every eight Australian general practices (about 900 clinics) to employ a pharmacist for two days each week and every ACCHS to employ a pharmacist for at least one day each week. At full scale, this would mean an extra 500 pharmacists working across general practice and ACCHSs, the report says.
Below, two of the report’s co-authors, Peter Breadon and Mia Jessurun, write that pharmacists have a lot to offer, particularly at a time of growing polypharmacy and healthcare demand, but “realising that potential will take good governance and strong evidence”.
Peter Breadon and Mia Jessurun write:
If you listened only to the Pharmacy Guild of Australia, which represents pharmacy owners, you’d think that rapidly expanding the number and type of services that pharmacies can offer was an obvious way to cater for the growing demand for primary healthcare.
On the other hand, the Royal Australian College of General Practitioners warns that such an expansion would fragment care and put patients at risk.
Our new Grattan Institute report shows that there’s more to the story.
Pharmacists have the skills to do more, and are available without an appointment in most communities. With the health system under pressure, policy should make the most of this valuable asset.
But a poor policy track record, the power of vested interests, and weak evidence of cost-effectiveness for some proposed pharmacy services mean Australia should proceed with caution.
Mismanagement
Funding and rules for many services are agreed in a negotiation between the Federal Government and the Pharmacy Guild.
One small improvement is on the way. The Government has committed to a new agreement covering some services, which will be negotiated with the Pharmaceutical Society of Australia, which represents pharmacists.
But while negotiating with the workforce instead of business owners may be an improvement, negotiation without independent evaluation and pricing is still the wrong approach.
No other major part of the health system is managed that way, and the reasons are obvious. Direct negotiation risks paying too much and can mean compromises on service design and targeting, rather than following the evidence.
We’ve seen these risks play out.
Nearly 10 years ago, the Medical Services Advisory Committee (MSAC) reviewed MedsChecks – brief medication reviews provided by community pharmacists – and found no strong evidence of clinical or cost effectiveness.
But since then, the Government has continued to fund MedsChecks – spending a further $356 million. And instead of reforming targeting as MSAC recommended, the Government limits spending with a cap of 20 MedsChecks a month for each pharmacy.
Similar caps apply to Home Medicines Reviews, and Dose Administration Aids.
This is the wrong way to manage costs. If you’re the 21st patient at your pharmacy who genuinely needs a MedsCheck, you face either paying out-of-pocket or being turned away.
Pharmacists aren’t required to communicate their recommendations from a MedsCheck with the patient’s GP, even if they think the GP should make prescription changes. This means that it’s on you, as a patient, to relay recommendations back to your GP.
MedscChecks need tighter eligibility criteria, so services go to patients at higher risk of medication-related harm.
And for all services, prices should be set independently, outcomes should be shared with the patient’s GP, and program rules should be set by government directly.
Value matters
Those changes would help lay the groundwork for new services. But that doesn’t mean that all proposed pharmacy services are ready to go.
Pharmacies overseas do provide a broader range of services than pharmacies in Australia, including prescribing for common short-term illnesses, monitoring patients with chronic illnesses, or conducting disease screenings.
Evidence shows that many of these services are safe, effective, and popular with patients. That makes sense, because pharmacists are highly trusted medicines experts.
But the evidence on whether those services are cost-effective is more mixed. And that makes sense too – because the community pharmacy setting presents risks to value.
Pharmacies are shops, not just healthcare providers. For many services, the same pharmacist would prescribe a medicine and then sell it to you. That could lead to unnecessary scripts.
Some patients end up going to the GP, even after receiving pharmacy care, meaning services are duplicated. And because pharmacy services are usually walk-in, with no appointment needed, patients sometimes seek care for issues that would have resolved on their own.
These problems have been seen repeatedly in international and Australian studies, so the Federal Government should test whether services are good value for public money before funding them.
In the past decade, there have been more than 20 government-funded trials in Australia of many different community pharmacy services. Almost all have failed to provide enough evidence to roll the service out, leaving the system in limbo.
Government should fund rigorous, independently designed, nationally coordinated trials. It should only test services where the evidence on cost-effective overseas is promising. These services include treating common illnesses such as shingles, prescribing for contraception, and working closely with a patients’ GP to help manage diabetes or hypertension.
There is one exception. There is enough evidence to justify rolling out pharmacy prescribing for uncomplicated urinary tract infections. But everything else should wait for decisive cost-effectiveness evidence.
All services that are cost-effective – including existing ones – need to be monitored for quality and safety.
Currently, the only quality program is run by the Guild, with no public reporting. A quality framework will push pharmacies to support their workforce to provide good care, reducing the risk that they put profits before patients.
Another model
In the meantime, another model can harness pharmacists’ medicines expertise with less risks to value: integrating pharmacists into primary healthcare, including GP clinics and Aboriginal Community Controlled Health Organisation (ACCHOs).
Integrated pharmacists are common overseas, and bring medicines expertise into a patient’s primary care team. Rather than selling medicines to patients, they provide medicine reviews and education. They also participate in case conferences, and advise GPs and other providers, about medicines-related issues.
Evidence shows that this model benefits patients, that pharmacists work well with GPs, and that it is good value for money. MSAC supported a model of integrated pharmacists in ACCHOs in 2023, which is ready for roll-out.
Pharmacists are highly-skilled medicines experts, they live and work in almost every community across the country, and they have a lot to offer, particularly at a time of growing polypharmacy and healthcare demand.
Realising that potential will take good governance and strong evidence. Otherwise, extra pharmacy services will cost a lot but won’t take pressure off a system under growing strain.
PostScript from Croakey
As of 14 July, the Guild had not published a media statement responding to the report, but a representative was quoted in this ABC report, which also said “Health Minister Mark Butler would not be drawn on whether the Government would consider the report’s recommendations”.
The Grattan Institute describes the Guild’s political power and history of blocking reforms: “In the past five years, it has donated $2.5 million to political parties. This makes it the largest donor from the healthcare sector over that period, and the 15th largest overall – larger than the Minerals Council of Australia. Over the past four years, the Guild has also spent $16.3 million on public campaigns.”
Croakey readers may not be surprised to see that the Australian Medical Association and Royal Australian College of GPs have welcomed the report.
Also see Croakey’s archive of articles on pharmacy
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