REPORT TO THE AUSTRALIAN GOVERNMENT REVIEW OF THE

6TH COMMUNITY PHARMACY AGREEMENT

REPORT ON CONSUMER
CONSULTATION ON REVIEW OF
PHARMACY REMUNERATION
AND REGULATION

Commissioned by the Department of Health

September 2016
 CONTENTS
Executive Summary..............................................................................................3
Introduction...........................................................................................................4
Purpose..............................................................................................................................................4
Consultation Process..........................................................................................................................4

Consumer views regarding community pharmacy...............................................5

Quality and safety..............................................................................................................................5
Health literacy...................................................................................................................................7
Access to medicines...........................................................................................................................8
Equity................................................................................................................................................9
Rural and remote communities......................................................................................................9
CALD populations.........................................................................................................................9
Aboriginal and Torres Strait Islander consumers...........................................................................9
Opioid substitution therapies.......................................................................................................10
Privacy.........................................................................................................................................10
Extension and recognition of the community pharmacy role...........................................................10
Community pharmacy as part of the wider system..........................................................................12
Models of Community Pharmacy....................................................................................................12
Non-prescription medicines.............................................................................................................13
Selling other items including complementary medicines.................................................................13
Affordability of medicines...............................................................................................................14
Consumer knowledge......................................................................................................................15
CPA and consumer involvement.....................................................................................................15

Areas for further focus........................................................................................16

Issues considered important but out of scope.....................................................17
Biologics and biosimilars................................................................................................................17
Cost of medicines............................................................................................................................17
Security of supply............................................................................................................................17
Consumer Medicines Information...................................................................................................17

Conclusion..........................................................................................................18

2 Consumers Health Forum of Australia

Executive Summary
As part of the 6th Community Pharmacy Agreement (6CPA) the Australian Government has
established an Independent Review of Pharmacy Remuneration and Regulation to provide
recommendations for reform. The Review started in November 2015 and is primarily a consumer-
focused Review that aims to identify which services and programs consumers value from community
pharmacy. The Review is also concerned with the sustainability and viability of an effective
community pharmacy sector. A key focus of recommendations from the Review will be ensuring
reliable and affordable access to medicines for Australian consumers and the quality use of medicines.
The Review has already consulted widely and has now produced a Discussion Paper, which forms the
basis of the next stage of consultation.

The Review Panel has committed to consulting widely with stakeholders, including consumer,
pharmacist, health professionals, hospitals, wholesalers and medicine companies. Interested parties
have been invited to submit directly to the Review, pharmacists and consumers have been invited to
complete an online survey and there has been a series of public events, including forums in each state
and territory.

The Consumer Health Forum of Australia (CHF) was commissioned by the Australian Government
Department of Health to collect and collate the views of consumer organisations in a targeted
consultation. The aim of the consultation was to ascertain

1. consumer attitudes to the services expected from community pharmacy

2. consumer expectations regarding access to and affordability of medicines; and

3. consumer priorities regarding access to and quality use of medicines.

The CHF held in-depth telephone interviews with identified stakeholders to gather consumer
representative views and conducted a telephone focus group with a sub-set of consumer stakeholders
to test the themes coming from interviews. Consumers discussed a broad range of issues to do with
community pharmacy. The key themes arising from the collated interviews are listed below.

 Community pharmacists have a key role to play in ensuring safety and quality in
medicine prescribing, dispensing and monitoring
 Community pharmacists can actively work with consumers and peak consumer bodies to
improve health literacy
 Access to medicines is a critical issue across the whole Australian population
 Improving access and equity for specific population groups, including those living in
rural and remote communities. Aboriginal and Torres Strait Islander consumers, and
consumers from culturally and linguistically diverse backgrounds is important when
considering community pharmacy into the future
 Privacy considerations in community pharmacy continue to be important to consumers
 It is important to recognise the full scope of practice of pharmacists and action an be
taken to extend the community pharmacy role accordingly
 Integrating pharmacy within the wider primary health care system will support better
care for consumers and maximise the health professional role of community pharmacists

CHF Report to Review of Community Pharmacy Remuneration and Regulation 3

  While most community pharmacies are retailers, there is variability in the extent to
which this is accepted by consumers. There needs to be diversity in models of
community pharmacy
 Consumer interest in the details of medicine pricing is variable
 The affordability of medicines continues to be important to consumers and the Pharmacy
Safety Net is not viewed as adequate
 The Community Pharmacy Agreement is no necessarily supported by all consumers
This report describes these areas in more detail, including examples and some suggestions for further
consideration by the Review Panel.

Introduction
Purpose
This document provides a comprehensive report on the consumer consultation for the Review of
Pharmacy Remuneration and Regulation, undertaken by the Consumer Health Forum of Australia on
behalf of the Australian Department of Health.

Consultation Process
The CHF held in-depth one to one structured interviews with identified stakeholders in August and
September 2016, including a focus group on 2 September 2106. Stakeholders represented the
following groups:

Alzheimer’s Australia Health Care Consumers Association of the ACT

Arthritis and Osteoporosis Victoria Health Consumers of Rural and Remote Australia
Inc.
Arthritis Australia Health Consumers Qld
Bowel Cancer Australia hearts4heart
Cancer Voices Australia MS Australia
Chronic Illness Alliance Pain Australia
Haemochromatosis Australia Koori Women’s Health Time
National Mental Health Consumer and Carer
Forum
The following questions were asked of consumers involved in interviews and identified themes were
tested with a small focus group.

What outcomes do consumers want to see from the Review?

Does the Review Discussion Paper capture the issues of importance to consumers?
Are there particular recommendations that would be a priority for consumers?
Are there additional issues consumers would like raised?
Are there issues raised that consumers disagree with?
What is important when community pharmacies are filling prescriptions and dispensing medicine?

4 Consumers Health Forum of Australia

 Do consumers think there are differences in the services provided in different models of community
pharmacy?
Would consumers like to know how prices of medicines are determined and the financial support
community pharmacies get for dispensing some medicines?
What do consumers think about community pharmacies providing medicines that do not require doctor’s
prescription but may be risky for some in some circumstances?
What do consumers think about community pharmacies selling other items as part of their business
models (e.g. vitamins, complementary medicines)?
Do consumers think the PBS Safety Net is adequate to address needs of low income consumers with
high medicine and health care costs?
What do consumers think could be done to improve access to medicines and advice for underserved
populations?
Do consumers feel that that arrangements are available for private discussions / service in the
pharmacists they access?

Consumer views regarding community pharmacy

Based on the consultation questions, a number of key
themes arose from interviews. These are described in the “What people want is basically
following paragraphs. Quotes from interviewees are health practitioners who will listen
highlighted to provide examples. and take a holistic view and see
consumers in the context of their
Quality and safety life.”

“That provision of information
to consumers about their
medicine is variable and
depends on which pharmacy or
even which pharmacist, and
sometimes these are
conversations that belong back
at the prescribing end”.
Most consumers
interviewed considered
the role the community pharmacist played in providing advice and
identifying potential drug interactions to be critical and that
community pharmacists have a key role to play in quality and
safety of medicines. Several consumers discussed personal
experience of community pharmacists providing useful and
supportive advice on medications. Prompts to take medication and
to have prescriptions refilled were considered by a small number
of consumers to be part of a community pharmacist role, especially
in cases where an individual may have some cognitive impairment.

A small number of consumers believed the role of community pharmacy involved not just dispensing
and supplementary advice but possibly real-time monitoring of medication with high risks e.g.
opioids, advising against purchase of a non-prescription medicine or contacting a GP to check a
prescription.

Most, but not all, consumers supported improved communication between community pharmacy,
allied health and doctors, especially in relation to
“While opioid monitoring is an issue
interactions or to substitution of medications and to use
for the whole health system,
of complementary medicine. One or two consumers
Community Pharmacists are a key
part. They have to be paid to do it -
and then
CHF Report to Review of Community do it.”
Pharmacy Remuneration and Regulation 5
believed community pharmacists had a key role in encouraging best practice in prescription of some
medicines, for example challenging routine prescription of opioids for chronic pain. However not all
consumers believed it was possible for a productive exchange between community pharmacists and
GPs if a potential safety issue was identified. One consumer expressed the opinion that there might
be differing views across general practice of the professional role of community pharmacists.

A small number of consumers noted that community pharmacists may or may not have a good
awareness of what medications a consumer was taking and that they should not be expected to take on
a monitoring role they could not fulfil. These informants pointed out that not only might some
consumers receive prescriptions from different doctors (specialists and GPs) but they might also be
purchasing non-prescription medicines from different sources or having prescriptions filled at
different pharmacies. The role of consumers in informing their health professional of all medications
they were taking was emphasised by this group.

Not all consumers thought medication reviews were an important component of pharmacy services.
However, those who represented consumer groups likely
“Older people get mixed up about
to be taking multiple medications, saw medication reviews
medications and with generic brands
as important. Examples included consumers with long
– they do not look the same (e.g.
term chronic condition, including mental illness, who
colour of the tablet). A home
might have been prescribed a range of medicines over
medicine review can get inside and
time.
look at the drugs and sort it out.
It was considered particularly important that medication Home medicine review is important
reviews took place in the consumer’s own home – the across the spectrum.”
expression “go through the bathroom cabinet” was used to
capture the need for a thorough understanding of all
medicines being taken, whether there were out of date medications still being kept (or taken) and what
non-prescription medicines were being taken as well. One consumer suggested a reminder system
could be in place, linked to prescribing systems, to ensure vulnerable consumers had a medication
review annually.

There was concern expressed by a small number of consumers that remuneration for home medication
reviews was not adequate for it to be attractive to community pharmacists and that current rules
limited the number of reviews that could be done, even in areas where more should be done. One or
two consumers suggested these reviews could be considered a sub-specialty and undertaken by
specifically trained pharmacists.

Some consumers believed it was important to incentivise delivery of quality service and quality
outcomes rather than providing payment for throughput. This would require development of a set of
outcomes measures (for example patient adherence to prescribed medicines). There was a view held
by a small number of consumers that while most community pharmacies worked effectively within
the current model it may not be correct to assume that all pharmacies were delivering quality service
within the current model. Several consumes noted that community pharmacies did not prominently
display certification of accreditation or achievement of quality and safety standards in their shopfront.

Health literacy
Most consumers considered community pharmacy had a key
role to play in improving health literacy and consumer ability “The most vulnerable people are
those least likely to have good
records or to understand the
6 Consumers Health Forum of Australia system.”
to take responsibility for their own health. Some considered this was an area where PHNs in
particular could work with community pharmacy.

Examples included community pharmacy working with peak consumer groups to develop and
promote materials to improve consumer awareness of specific conditions, such as bowel cancer,
diabetes, musculoskeletal disorders and chronic pain. These are conditions where advice and
information, provided by a reputable source, may assist consumers to ameliorate the impact of their
condition and complement information provided by their doctor. This included information on non-
medicated ways to manage chronic conditions within the context of the individual’s life (e.g. pain
management). Several consumers discussed the need to make this information easy to read and
understand, including using pictures and local language/slang where necessary. While it may not be
the responsibility of the community pharmacist to develop these resources, these consumers felt they
had a role to play in making sure this information was available for different literacy levels.

Several consumer representatives from these peak

bodies noted that they were already or planning to work “There are 44 different things you
more closely with the Pharmacy Guild on this issue. can do for pain management and
one is drugs. Nearly all of these are
A small number of stakeholders held strong views on
available at a pharmacy.”
medication information for consumers, noting it is
important to address the current lack of information
about prescription drugs for consumers (CMI).
Although some issues, such as inclusion of CMI in packaging, are beyond the scope of a community
pharmacist, they believe community pharmacy can play a key role in providing written and verbal
information in language and readily understood format at point of dispensing. It was noted that 70%
of consumers get no information on prescription drugs (unreferenced). This was extended to
information about Schedule 2 and 3 drugs as well.

Several consumers noted that there needed to be some intelligent application of the requirement to
provide information. For some consumers on long term medications, who have received information
and have good levels of health literacy, information provided every time the drug is dispensed may
not be necessary. For others, information to patient and carer every time a medication is dispensed
may be better practice.

People with lesser known conditions would like to feel confident that if they walked into a pharmacy
with questions about their condition they could be
confident that staff could access information easily and “I do not expect every pharmacist to
direct them to reputable sources of information. know about my condition, but if it is
Consumers noted this might require organisations my local pharmacist I do expect it”
representing particular conditions, working with
pharmacies to help disseminate information to
consumers, particularly for lesser known conditions. An example provided was that of people with
haemochromatosis, a little known disease where intake of iron supplements is contraindicated.
Another example was provided of a peak organisation working directly with the Pharmacy Guild to
publicise a specific condition. There was a significant response from community pharmacies asking
for information on the condition, following an article in the Pharmacy Guild newsletter.

Access to medicines

CHF Report to Review of Community Pharmacy Remuneration and Regulation 7

All consumers considered that access and flexibility in prescribing and dispensing medications were
important, especially to increase access for disadvantaged groups.

Some options suggested by consumers included online

prescribing and delivery, arranged through the GP “With technology and things like
practice, home delivery for housebound clients (within telehealth, services after hours
the context of safe provision of medications advice), should be available from a central
telehealth and delivery by school bus or through hub. We can use technology more
visiting health providers to people living on the land in for after-hours service - for
small rural communities. community pharmacy as well as
general practice.”
Within metropolitan and larger regional areas, most
consumers felt that a roster system for after-hours
services across a geographic location would be
adequate for addressing out-of-hours medication requirements. Several consumers noted that the
practice of hospitals providing a week’s worth medication on discharge was important in maintaining
medication use until a consumer could get to a pharmacy. One consumer described situations where
patients were provided with one day’s medication only and noted the difficulties this presented for
rural and some Aboriginal patients.

All consumers agreed there were specific populations that were underserviced, including by
community pharmacy. There was a general consensus that action should be taken to address
inequities and inequality in service delivery. This is covered in more detail further in the report.

The Community Service Obligation was discussed by a small sub-set of consumers, particularly in
relation to increasing numbers of medications requiring cold storage and specific handling. The CSO
is intended to ensure that people living in rural and remote areas get access to the medicines they need
in time. However, with increasingly specialised medicines being made available through community
pharmacy, there is a significant burden on pharmacists in terms of cold storage and purchase cost.
The consumers discussing this issue were aware of this and felt there was a need to consider
innovative solutions, such as accrediting specialist ‘hub’ pharmacies to manage issues of cost, supply,
safe storage and transport to enable access across Australia.

Locality rules were also discussed by several consumers, who felt that these rules were protecting the
interest of pharmacy rather than considering the needs and preferences of consumers. This group
believed the market should determine the location of community pharmacies.

8 Consumers Health Forum of Australia

Equity
Rural and remote communities
The general view held by consumers was that in rural and remote communities sometimes a
pharmacist is the only health professional in town so they need to be able to deliver a variety of
services and products in an affordable and accessible way. Some consumers felt strongly that
universal access for Australians in rural and remote areas should remain a priority and that it is
important that Review recommendations set a scene for positive outcomes and better quality service
for rural and remote consumers.

Most suggestions related to increasing access in rural and remote areas through innovative methods of
dispensing and delivering medications. Models of delivery in rural and remote communities were
discussed, and the role that appropriately trained and supported pharmacy assistants play in those
pharmacies that are dependent on part-time visiting pharmacists. The need for safe and flexible
processes to support delivery of dispensed medicines to these small rural communities and
homebound rural residents was highlighted. Suggestions for providing medicine to rural and remote
consumers included:

 Telehealth
 Delivery by school bus
 Through visiting health providers
 Using exiting local facilities such as AMS, residential aged care facilities or community
health centres.
One consumer suggested a population-based system of supporting pharmacies to remain open in rural
areas to address the issue of economies of scale and dwindling pharmacy numbers in small towns.

CALD populations
A small number of consumers discussed the importance of having information available in languages
for people from culturally and linguistically diverse background. One or two consumers who had
undertaken consultation with CALD consumers noted the importance of identifying their
understanding of the Australian health system. Experience with the role of community pharmacy in
other countries might be different from the Australian models and shape the use of these services by
some CALD consumers.

A small number of consumers reported experiences with CALD consumers where they heard stories
of potentially life-threatening misinterpretation of dosage instructions on prescribed medicine, due to
language difficulties or ambiguity in dosage directions. Suggestions for increasing access included
employing pharmacists from the same language groups as the local CALD communities.

Aboriginal and Torres Strait Islander consumers

A number of consumers held views on the issue of equity and access for Aboriginal and Torres Strait
Islander consumers, and a single consumer specifically representing Aboriginal consumers was
interviewed. The issue of racism in the delivery of services to Aboriginal and Torres Strait Islander
consumers was called out as a continuing issue, manifesting more noticeably in rural communities.

CHF Report to Review of Community Pharmacy Remuneration and Regulation 9

This impacted on the willingness of these consumers to engage with traditional community
pharmacies.

Consumers that provided input on this topic noted the importance of having a community pharmacy
delivery model that aligned with Aboriginal and Torres Strait Islander views of healthcare. Models
where community pharmacy was provided as part of an overall community health service (through an
Aboriginal Community Controlled Health Service, General Practice or another venue) were described
as more attractive and appropriate. These models placed the community pharmacist in a health care
rather than a retailing environment, which gave them greater credibility with the community.
Consumers pointed out that models such as this are not for profit and therefore require a different
funding mechanism.

Opioid substitution therapies

One consumer noted an inequity in the distribution of opioid substitution therapies through
community pharmacies and that it did not match the distribution of consumers requiring this therapy.
This consumer questioned the assumption that community pharmacists should be able to choose
whether they dispensed certain medicines or not.

Privacy
All consumers believed access to private space in the community pharmacy was important. Some
related seeing private spaces being used in local pharmacies, while others did not. A small number of
consumers raised practical issues regarding using private spaces and taking pharmacists away from
other dispensing tasks. The question was asked: “should this level of service be by appointment?”
One consumer expressed the view that this service might be provided through MBS, rather than PBS
billing.

Most consumers recognised there were some conditions that might be considered more sensitive but
also that sensitivity was contextual, for example privacy concerns might be greater in small rural
towns. A small number of consumers related stories of seeing clients receiving opioid replacement
therapies being allocated (publicly) a special place to wait for their medication. Several consumers
suggested that, at the very least, the use of booths at the dispensary counter could increase privacy.

Extension and recognition of the community pharmacy

role
Almost all consumers felt the professional role community
pharmacists play in the health care system should be “There should be standards about:
recognised and separated from the retail component of many
community pharmacies. Several consumers noted that  information provided,
pharmacists are not necessarily asked to perform to their full  rights and responsibilities,
scope of practice because of the retailing environment in  what services community
which they work. At last one consumer expressed the view pharmacies should provide,
that the CPA addressed the needs of pharmacy owners but did  space for privacy,
not necessarily support the full scope of practice of  follow up, error rates,
pharmacists employed in community pharmacies.  clinical reviews,
 medication reviews.”

10 Consumers Health Forum of Australia

Most consumers had suggestions for how the pharmacy role could be recognised in its entirety but
also extended. Public marketing of the range of services that can be provided by community
pharmacy could increase community awareness and use of these extended services.

Several consumers mentioned the “Ask your Pharmacist” campaign as an example of promoting the
range of services provided through community pharmacies. Some consumers believed that
community pharmacies did not have in place the signage and notices to consumers that could prompt
consumer demand for the full range of pharmacy services that could be provided. Consumers,
therefore, did not ask for these services.

Suggested extensions to the current community pharmacy role included:

 Provision of education sessions for consumers on specific diseases, for example on the
early signs of diabetes
 Health promotion and disease prevention, including nutrition and healthy lifestyle advice
to help prevent development of some conditions
 Screening (in addition to bowel screening kits), including breast checks for breast cancer
 Immunisation, for those who do not access GP services for this
 Provision of repeat prescriptions, under a health care plan by a medical practitioner, for
specified conditions
 Information and support for chronic pain management, including the non-medicated
components of pain management and advice on opioid use
 Chronic disease self-management, including lifestyle advice
 Aged care, including medications and specific conditions such as dementia
Consumers noted some pharmacies already provide some of the above services but believed a number
of these services would require additional training,
accreditation and monitoring before they could be provided “For example with Dementia – you
through community pharmacy. The idea of post-graduate want people to walk in and be able
training is these specialist areas was raised as an option to be detected at earliest possible
point. You want pharmacists and
Consumers also acknowledged that extension of the staff to say to people “have you
pharmacy role in this way would require some form of thought about this?” and give
payment, which might be by the consumer or through pointers about risk reduction, and
Government subsidies and incentives. Consumers noted early detection. If you are paid for
that the question of consumer paying for services had not throughput you do not have that
been raised or explored fully in this Review or on other time”.
forums.

One or two consumers reminded us that pharmacy assistants

are trained and required to follow certain procedures in their interactions with customers about
pharmacy products. This was considered significant in the light of rural access to pharmacy services
and in relation to advice on complementary medicines.

CHF Report to Review of Community Pharmacy Remuneration and Regulation 11

Community pharmacy as part of the wider system
Almost all consumers believed it is important to recognise community pharmacy as part of the wider
health care system and strengthen collaborative practices
“If you are a community pharmacist
with general practice and other primary health care
maybe you are obligated to spend ½
providers, for the benefit of consumers. Incentives and
day over at the local community
support for community pharmacy to work collaboratively
centre as a community pharmacist –
with other groups and take a co-ordinating role as part of
… providing advice, dispensing and
health care teams may be important.
reviewing.”
Some consumers reported there was not enough emphasis
on collaboration and the role of community pharmacy
working as part of PHNs. The abolition of silos and greater collaboration between primary care
providers, including community pharmacists as part of GP teams was encouraged, and may require
additional effort by community pharmacists as well as other part of the primary health care system.

Models of Community Pharmacy

Opinions were divided on the issue of quality and safety in
different models of community pharmacy. While some “I have had great advice
consumers believed there were differences in the quality of advice from discount pharmacies.
and support provided in discount pharmacies, others believed that It comes down more to the
the professional responsibilities of pharmacist were the same no profession and how they
matter what the retailing model of the community pharmacy, and support and train their
that advice and quality of care were similar. Examples were health professionals and
provided of positive and negative interactions in both discount how information is
pharmacies and in more traditional models of community distributed.”
pharmacy.

Approximately half of the consumers interviewed described

discount pharmacies using terms such as “busy”, “confusing”, “crowded”, but a smaller number
considered this impacted negatively on the pharmacists’ provision of medicine dispensing and advice.
Several consumers pointed out that pharmacists in the discount pharmacy model may be less likely to
be on the floor to provide advice on non-prescription medicines, although at least on consumer
challenged this view, citing personal experience. One consumer noted that there needed to be variety
and choice in the market, and several consumers pointed out that many individuals selectively chose
when they used a discount pharmacy and when they did not.

A small number of consumers challenged having any form of retail model for pharmacy, believing
that it negatively impacted on the role of the pharmacist as a health care provider. Conversely,
another small group of consumers challenged the concept that community pharmacy had to be
provided through chemist shops only, and could not be provided through supermarkets or other
venues as well. The underpinning belief held by approximately half of the consumers interviewed
was that community pharmacists are university trained and accredited professionals who understand
very well their professional obligations and can practice these in a number of different environments.
Consumers then had personal preferences as to which models they considered most appropriate or

12 Consumers Health Forum of Australia

attractive. Several consumers discussed a model where community pharmacists were linked with
general practices and/or residential aged care facilities – perhaps through the proposed Health Care
Home model.

Non-prescription medicines
Generally speaking most consumers felt that the provision of advice was essential in the provision of
Schedule 2 and Schedule 3 medicines, even noting that many have information inserts in the
packaging. However not all believed this had to be through a community pharmacy. Most consumers
agreed that the risk associated with these types of medicines warranted qualified advice of some kind.
Several consumers believed this advice should come from a pharmacist and not from pharmacy
assistants or other pharmacy staff.

One consumer noted the differences in policy and practice regarding these medications across
different states and territories. For example, in one state, consumers may have to provide their name
and address to purchase a particular S2 medication but this might not be the case in other states. This
inconsistency was considered confusing and an area that could be addressed through the Review.

A significant minority of consumers expressed the view that convenient access to these medications
when they were needed might mean more to consumers than having advice on the use of medicines or
potential risks.

Selling other items including complementary medicines

Approximately half of consumers interviewed believed that community pharmacies were a trusted
source for information and purchase of medicines and that
“There is an important role for
this carried with it a responsibility to avoid selling what one
complementary medicines and
consumer termed “snake oil” type products.
pharmacists may well be
Opinion as to whether pharmacies should sell complementary recommending them to customers for
medicines, vitamins or other health related items was divided. specific conditions.”
For a small minority of consumers there was a clear line
between what should and should not be available in a
community pharmacy – this being whether there was sufficient evidence upon which to base a
professional recommendation for use. For those interviewees representing consumers experiencing
chronic pain, there was a clear place for well-advised provision of complementary medicines.

However, one consumer discussed the impact on

“There needs to be lot more honesty
about the benefits of taking the
medicines – helping people make
informed choices, not unduly
influenced by the position of the
pharmacist.”
at least be able to provide some knowledgeable advice about them.
vulnerable consumers of seeing complementary medicines
available in a community pharmacy and cited examples
where vulnerable consumers were offered a complementary
medicine for which there was little or no evidence of
efficacy in staving off dementia. Another consumer
suggested the Australian Government might have a role to
play in quality control of complementary medicines. Most
consumers believed that people would buy complementary
medicines anyway and that community pharmacists might

CHF Report to Review of Community Pharmacy Remuneration and Regulation 13

There was also a school of thought, held by about half of consumers, that community pharmacy
functioned effectively as a retailing environment, with
I would like to see a big sign saying
pharmacy services being separate and recognised as
“You have a right to know about
different from the retailing “store front”. These
your natural medicines” or “Your
consumers held the view that retailing enabled financial
Community Pharmacist should
viability and helped keep community pharmacies open,
provide you with information about
especially in areas of lower population. Consumers who
this medicine”.
held this view also noted that there was a balance to be
achieved between financial viability and professional
responsibility and that it could be challenging to get that balance right.

Several consumers suggested that positioning the medications dispensing and advice at the front or
side of the shop might reduce the impact of the retailing component of the business and positively
increase focus on the pharmacy side of the business.

A significant minority of those interviewed noted that there are consumers who really value having
complementary medicines and would want to continue with that access through community
pharmacy. Any suggestion that this is not valuable would be roundly rejected by these consumers.

Affordability of medicines
Most consumers felt the PBS Safety Net was necessary but not adequate. A number had personal
experience of dealing with large health care costs and not meeting the threshold, because some of
their medications were complementary or not included in the PBS.

Some consumers pointed out that the Safety Net kicked in

“There are people who do not have late in the year for many consumers, but their low income
prescriptions filled or halve their levels were in place all year, so before meeting the
medication rates to eke them out for threshold individuals may have made decisions about
longer. This compromises their reducing doses or missing days to reduce costs. This could
health.” compromise the effectiveness of medications. There were
some suggestions that other methods of calculating the
threshold might be applied, for example averaging out
likely health care costs over 12 months and sing this figure
to determine if an individual met the Safety Net threshold.

There was a view that the PBS Safety Net was cumbersome
and relied too heavily on the capacity of individual
consumers to record and track their medication purchases.
The view was that the system should be simplified and/or
automated as much as possible. Consumers cited the MBS
safety net and pointed out that it was automated and did not
require patients to maintain records, attend the same doctor
or track their own use of services.
Several consumers felt that the most disadvantaged and
vulnerable consumers might be the ones most likely to slip
through the PBS Safety Net because of the requirements to
“You have to know a lot about the
system and how it works or be
supported by a pharmacist to collect
the information needed and access
the support. It is not well known and
unfortunately for more vulnerable
populations it is not set up to work
for them.”

14 Consumers Health Forum of Australia

track purchases. At least one consumer considered investment made in the CPA could be better
targeted to reducing the cost of medicines for vulnerable consumers.

Consumer knowledge
Consumer awareness of the range and extent of pricing and payments for dispensing varied. Opinions
differed on the issue of whether consumers should be provided with more information on pricing and
payments for medications, prescribing and dispensing. Most consumers who considered people
should be provided with more information felt this was specifically the case for medication pricing
and discounting to the consumer. There was a view that if consumers understood the extent to which
some medications were subsidised by the PBS they might value them more and increase compliance.
Several consumers noted that the actual cost of medicine and the subsidised cost are printed on
dispensing labels and this is of interest.

A small number of interviewees expressed the view that consumers would not be interested in pricing
and discounting mechanisms – that the priority was access to affordable and available medication
when needed.

Greater transparency was called for by a small but vocal minority on the role of community pharmacy
in the whole area of prescribing and dispensing and greater transparency on remuneration. This
included development of outcomes measurements and publicly reportable KPIs for community
pharmacy. These views were strongly held. There was a call by this group for greater transparency in
funding and incentives for community pharmacy and the Pharmacy Guild.

CPA and consumer involvement

A small but vocal minority questioned the value and rationale for the CPA – noting that it did not
appear to exist to benefit consumers. In particular they were concerned about open and transparent
accounting of funds allocated through the CPA to various fund holders. One consumer suggested s
system of KPIs be required for the CPA, that addressed outcomes for consumers and that this include
accounting for Government funds spent.

One or two consumers expressly noted their appreciation for

what they saw as a genuine effort by the Review panel to hear
“Should there have been an opening
and include the voices of consumers. However, a small
question – “What would an ideal
number of consumers noted that it is important that a broad
pharmacy service look like and how
range of consumers are included in any future discussions
do we get there?” If a 7th CPA is
around the Community Pharmacy Agreement from the
developed, should it move away from
beginning (three years out) and are engaged in achievement
a bilateral agreement and should
of outcomes.
this question be the starting point for
One consumer noted the Discussion Paper makes some its design?”
assumptions about what consumers want from pharmacy
rather than testing those assumptions first.

CHF Report to Review of Community Pharmacy Remuneration and Regulation 15

Areas for further focus
Based on the question – “Are there particular recommendations consumers would like to see”, the
following areas were suggested by some or most consumers as areas of focus for the review moving
forward.

1. Development of publicly reportable KPIs for any future CPAs that align funding to health
outcomes.
2. Understanding (through audit) and public reporting how public money is spent through the
CPA and how money is spent on effective use of medicines by consumers.
3. Increasing the extent and diversity of consumer engagement throughout CPA negotiations,
with a range of consumer representatives at the table and broader review of negotiations at
key points by consumers.
4. Monitoring the extent to which information on medicines is provided by the community
pharmacist when dispensing. This is in addition to any written material provided by
pharmaceutical companies in medicines packaging, and should involve verbal information at
the least.
5. Consideration of extended roles for community pharmacy as part of the primary health care
system, (for example in the Health Care Home) including funding streams that can support
extension of the community pharmacy role. Consideration of the extent to which consumers
can be asked to pay for extended services and the role of government in funding extended
services. Discussion of training and accreditation for community pharmacists providing
extended services.
6. Promotion of the full range of health care and advice (e.g. list on the wall) that can be
provided by community pharmacies, including engagement of specialist consumer and
disease-specific peak bodies in provision of information.
7. Consideration of the community pharmacy role of “gate keeper” for identifying and
addressing potential medicine interactions, separate from a full medication review. This
includes establishment of easy processes for consumers to track and keep a record of their
own prescribed and non-prescribed medicine use, and may be linked to the inclusion of PBS
information in My Health Record.
8. Consideration of electronic tracking systems to improve safety and quality medication
monitoring, for example monitoring unfilled prescriptions (compliance) and frequency of
opioid prescriptions
9. Review of locality rules to improve access for rural communities and consideration of the role
of the RFDS in delivering medicines to remote communities
10. Review the current process for accreditation and professional development for community
pharmacy.
11. Review the current processes to activate the PBS safety net, including consideration of
automated processes as for the MBS safety net.

16 Consumers Health Forum of Australia

Issues considered important but out of scope
A number of issues were raised in consultations that were not strictly in scope for this project.
However, they were strongly held by consumers and are included here for the information of the
Department.

Biologics and biosimilars

A small minority expressed strong views on the current system for allowing a-flagging of biosimilars
for biologics. These consumers were concerned that there might be differences in the effect on a
patient, because of the variable nature of these medicines, and that consultation should occur with the
prescribing doctor and the consumer before a substitution was made, as per PBS advice 1. Currently
prescribers do have the option of ticking a box on the prescription to avoid substitution

Cost of medicines
Cost is a barrier for access to some needed medications, (e.g. inflammatory arthritis, MS). In Australia
the TGA approved disease modifying therapies for MS are listed on PBS - this should continue as
new drugs are approved.

Security of supply
Consumers were concerned about security of supply as new drugs come on the market. Suggested
areas of focus included identifying inefficiencies and unnecessary subsidies, and reviewing
purchasing options for high cost drugs (such as oral chemotherapy) to support access through
community pharmacies. In particular a small group of consumers were concerned that people have
continued access to pharmaceutical products they need when they need them, by addressing issues
related to cost to pharmacy to purchase high cost drugs prior to supply to consumer.

In addition, the issue of some hospital Emergency Departments not being able to write Closing the
Gap prescriptions was raised as an issue for Aboriginal and Torres Strait Islander consumers requiring
medicine and not able to afford it.

Consumer Medicines Information

A small group of consumers held strong views on the issue of consumer medicines information and
re-establishing the requirement that pharmaceutical companies to insert a one page easily understood
CMI in all medicines packaging so written information is received by consumers at point of sale.
This group felt online information about medications should also be readily accessible and provided
in easy to understand language, reviewed by consumers.

1
http://www.pbs.gov.au/info/publication/factsheets/biosimilars/biosimilar-medicines-factsheet-for-healthcare-
professional

CHF Report to Review of Community Pharmacy Remuneration and Regulation 17

Conclusion
This report is based on in-depth interviews held with a range of representatives from consumer group.
It summarises and describes the key issues of importance to these consumers. Consumers are not a
homogenous group and have a wide range of views and experiences. It is important to note the
variability in responses to particular issues, for example the role of different models of pharmacy,
pharmacists as retailers, and the selling of complementary medicines.

This report captures that variability and suggests the Review Panel keeps in mind that the greatest
level of agreement was in the areas of quality and safety in medications, the role of the community
pharmacist in improving health literacy, recognition and promotion of the role of the community
pharmacist in the wider health system, supporting community pharmacists to work at top of scope,
and improving or maintaining affordability and access to community pharmacy (medications and
advice) for all populations.

The CHF would like to thank the consumers involved in this report, who gave freely of their time and
provided open and honest responses to the interview questions.

18 Consumers Health Forum of Australia