National Competition Policy Review of Pharmacy July 1999

National Competition Policy Review of Pharmacy

COUNCIL ON THE AGEING (AUSTRALIA)

1999 INTERNATIONAL YEAR OF OLDER PERSONS

Submission to

The National Competition Policy Review of Pharmacy

July1999

The Council on the Ageing (COTA) considers that the National Competition Policy Review of Pharmacy offers an important opportunity for consideration of the role of pharmacies in the Australian health system.

COTA recognizes that the public, including older Australians, have a high regard for pharmacists and the services they provide. However, COTA is aware that pharmacists hold a monopoly position in the supply and distribution of pharmaceuticals. This may be having the effect of contributing to higher costs for pharmaceuticals particularly the over-the-counter (OTC) and pharmacy-only medicines not subsidised under the Pharmaceutical Benefits Scheme (PBS). There may also be an effect in restricting access to pharmaceuticals in areas, especially rural and remote, which do not attract the establishment of a pharmacy business.

Older people in Australia are the major users of health services. Older people are prescribed and consume a wide range of medicines. Key issues for older people are:

Access to pharmaceuticals when and where they need them. As major users of prescribed, pharmacy-only and over-the-counter medicines, older Australians need to have access to pharmacy services as they would to any other health services.

Affordability of prescribed, pharmacy-only and OTC medicines. Prescribed medicines are provided under the Pharmaceutical Benefits Scheme (PBS). For older Australians with a Commonwealth Health Care Card, (including all pensioners, part-pensioners and self-funded retirees up to set income limits) the cost of PBS medicines is $3.20 per script. For those with a Commonwealth Health Care Card, there is a safety net limit after which PBS medications require no co-payment. The issue for many older Australians however is the extent to which the total expenditure on medications including PBS, pharmacy-only and OTC medicines remains affordable. This is emerging as an important financial issue for older people in residential care. Numerous medicines have been de-listed from the PBS in recent years. This means that there are now a number of medications which older people must purchase without a PBS subsidy.

The need for expert scrutiny of, and advice on, the range of medications being consumed by older people. Older people taking a number of medicines both prescribed and OTC are at risk of experiencing adverse drug reactions and interactions. In a study conducted by the National Ageing Research Institute on behalf of COTA, general practitioners were unaware of the use of 26 per cent of preparations their patients were taking. Older people are more likely to experience problems with the management of drug therapy due to the physiological changes with ageing including short-term memory loss, social circumstances and the increasing incidence of chronic conditions. It is good practice for pharmacists to conduct reviews of medications in conjunction with general practitioners particularly for people with high and long term pharmaceutical usage.

The majority of older people are on low incomes, primarily the Age Pension. The costs of pharmaceutical drugs may be a barrier to the wise use of medicines. Pharmacists have a major role in advising and providing older people with information about their medicines including costs, and assistance with managing complex regimens of medications.

In this submission, COTA comments on the three specific areas of pharmacy endeavour identified in the discussion paper.

OWNERSHIP OF PHARMACIES

COTA believes that high quality pharmaceutical distribution services are likely to be most effectively delivered under the present system of pharmacist-owned pharmacies. There may also be a case to explore the advantages of other forms of ownership involving small group practices with general practitioners.

If restricted ownership is to continue, it should be seen by pharmacists as a privilege, which can only be justified if they offer community pharmacy services that meet minimum requirements recommended below.

COTA recommends that:-

Older people have access to pharmaceuticals either through a community pharmacy or through home delivery or by mail order from wholesalers or self-help groups.

An individual's prescribed drug history is maintained by pharmacies.

Pharmacies exhibit clear price competition through advertising prices of OTC and pharmacy-only medicines including those pharmaceuticals removed from the PBS over the last five years.

The provision of consumer medicines information and advice is a mandatory component of dispensing medication new to the individual consumer. This information and advice would include advice regarding timing and level of dosages, side-effects, possible interactions, adverse reactions and disposal of unused medicines. There is a strong case that consumer medicines information should be available on the internet, including in community languages.

Pharmacies are located in local population centres and preferably within walking distance of localities with significant numbers of older people.

LOCATION OF PHARMACIES

Access to a pharmacy is increasingly a very important component of health care for the majority of older people. Older people are likely to be consuming a number of prescribed and over the counter medicines simultaneously. This leaves them vulnerable to adverse drug reactions and interactions. Pharmacists play an invaluable role in advising older people about prescribed and over the counter medicines. Pharmacists are able to alert older people to possible interactions and review their medicines regularly to ensure the maximum benefits to health are achieved.

The numbers of older people particularly the over 80's (old old) will continue to increase into the next century. The location of pharmacies in metropolitan areas will need to take the increased numbers of very old people and where they live into account. In metropolitan and the larger regional centres the location of community pharmacies will be crucial for access by older people. COTA supports the location of pharmacies near public transport, major shopping areas, health and medical services, large multi-disciplinary centres in suburban and regional centres, aged care facilities etc.

For the growing numbers of older people living in rural and isolated communities more flexible approaches to providing pharmacy services may be needed. For example, mail order pharmacy which is supplemented by a toll free consumer drug information service staffed by professional pharmacists is one approach worth investigating. Pharmacies could also be located in regional multipurpose centres and day care facilities.

House bound older people in urban areas experience difficulty in accessing pharmacy services. Some community pharmacists offer home delivery service of medicines to meet this need.

This service may also need to be expanded and supplemented by a toll free telephone drug information service staffed by pharmacists. Pharmacists who provide these flexible services should be acknowledged as they are meeting the needs of a highly isolated and vulnerable group.

It is perplexing to service users to understand the separation of general medical practice from the dispensing of pharmaceuticals. There are both cost and access issues in separating prescribing and dispensing. In the case of a vaccination, a person will normally visit a medical practitioner, receive a script, visit the pharmacy, return with the vaccine and then be injected. The cost is two medical visits and the older, frail person has an unnecessary visit to an off-site pharmacy. COTA would welcome general practices which include a pharmacy.

COTA recommends that:

6. Flexible approaches to delivering pharmacy services needs to be developed for people living in rural and isolated communities and housebound older people and their carers. For example, a toll free consumer drug information service may be needed to supplement the delivery of prescription and OTC pharmaceuticals by mail or courier.

7. Pharmacies are encouraged to co-locate with general practitioners. This could also involve co-ownership with general practitioners.

REGISTRATION OF PHARMACISTS

A life long learning approach to health and pharmaceuticals is as relevant to pharmacists as it is to all other health professionals. The number of drugs listed on the Pharmaceutical Benefits Scheme has grown substantially and many more new drugs are now available. A high level of knowlege and skill is required to ensure that the right drug in the correct dose is dispensed to an older person. Continuing education is essential for pharmacists. A mechanism is needed to ensure that knowledge about these new products is continually updated. It is pharmacists who provide advice and information to the community on the benefits and risks of specific medicines. Pharmacists will need to be "at the cutting edge" in terms of information about new products.

Education and training on the use of information and communication technology would be useful for pharmacists who received their formal pharmacy education before computer training was part of the curriculum.

Use of information and communication technology in the future may also assist pharmacies to improve the quality of prescribing decisions as well as keep accurate medication histories of people who use the same pharmacy. Communication between pharmacists and other health professionals may also be greatly assisted by the use of technology.

Mechanisms are needed to track each individual's use of pharmaceuticals. All PBS scripts that are dispensed are recorded with the Health Insurance Commission. This information should be available to pharmacists with the consent of the customer. This would mean that any pharmacist would be able to log into a customer's name and view pharmaceuticals dispensed by another pharmacist. Privacy and consent issues need to be addressed.

Communication skills are also an essential skill for pharmacists who provide pharmaceutical information to the public. Continuing professional education is supported and encouraged.

Pharmacists need to make available confidential areas in their pharmacies to advise customers on the use of pharmaceuticals. Hearing loss is common in older people and this needs to be taken into account when considering areas for providing confidential advice.

COTA is aware of concerns by community pharmacists if large retailers become pharmacy owners. COTA believes that the five minimum requirements (recommendations 1-5 above) must be met in planning the future of pharmacy in Australia. In planning the location of pharmacies, the ageing of the population needs to be considered. COTA believes the current Agreement controls on location and relocation are a justifiable restriction on competition so long as there is the opportunity for pharmacies to co-locate with general medical practitioners.

COTA recommends that:

8. Pharmacists are required to undertake continuous professional education and training to ensure they are able to offer a high level of service based on the most current information available on the pharmaceuticals they dispense. Education and training also needs to cover information technology, communication skills and best practice in the running of pharmacies to meet consumer needs.

9. Mechanisms are developed that enable the tracking of consumer's use of pharmaceuticals.

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Council on the Ageing (Australia)
Level 2, 3 Bowen Crescent, Melbourne Vic 3004
Tel (03) 9820 2655 Fax (03) 9820 9886
email cota@cota.org.au