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The theme
of my presentation today comes in a timely manner as the Cooperative
Research Centre (in Darwin) for Aboriginal and Tropical Health
is embarking on a review of the arrangements for the supply of
Pharmaceutical Benefits System (PBS) items to remote health clinics
using the provisions of Section 100 of the National Health Act.
What I am
about to tell you presents an alternative model for improving
the Quality Use of Medicine (QUM) in remote Aboriginal communities
by the astute use of the PBS through the obtaining of an Approval
Number to the supply of PBS with the surplus from trading being
put back into an improved way of medicine supply to remote living
Aboriginal people.
The model
of pharmacy practice you will hear about would not have been possible
without the PBS and the Section 100 arrangements.
I hope other community controlled health organisations will take
note, as well as the APAC, the Pharmacy Guild, NACCHO and the
CRCATH Review Steering Committee.
The Tiwi Health
Board Pharmacy Project has "pushed the boundaries" in
establishing a pharmacy service to remote living Aboriginal people.
I will look at the new ground that was broken and then my colleague
Linda will describe for you the service as it currently exists
at Nguiu, her home town.
I want to begin by thanking the wonderful Tiwi people for giving
me the opportunity to work amongst them over the past two years.
I have made enduring friendships and learnt a lot.
The areas where the boundary has been pushed out to take in new
ground are the following
* Ownership
of "pharmacies"
* Location of PBS approved pharmacy
* The function of "remote" pharmacy
* IT system to suit patient needs
* Indigenous "pharmacy technicians"
The question
of ownership and PBS location is crucial to the successful achievement
of the rest.
It has provided the resource to make the rest happen.
We have shown that the most effective way of improving the quality
use of medicine in a remote Aboriginal health setting is to put
a pharmacist out there to work with the clinic staff.
* Ownership of "pharmacies"
The mandate
for the Tiwi model was established by the fact that the Northern
Territory (NT) Pharmacy Act does not state who should be able
to own a pharmacy. Anyone can own a pharmacy in the NT so long
as there is a registered pharmacist in charge while the doors
are open.
In the Northern
Territory there is the potential for 23 pharmacy approvals to
be granted to each of the emerging health zones. This would embrace
all of the remote Aboriginal communities that will come under
community control with their own "health board".
They
(the PBS location rules) do not help to keep the shape of the
community pharmacy industry abreast of current and likely future
trends in consumer need and demand for pharmacy services, including:
* Specialist health care facilities such as Aboriginal Medical
Services, which could also sustain their own dispensary facilities.
NCP Review
of pharmacy regulation
A submission
from the Nguiu Pharmacy is currently before the Pharmacy Guild
for Associate Membership and this may give some recognition of
the status of Aboriginal owned pharmacies which I hope will grow
in the future as the needs of remote living Aboriginal people
is recognized as being a specialist field of practice.
It is now
only two years until the start of the Fourth Community Pharmacy
Agreement and I urge all official pharmacy bodies and the Aboriginal
health industry lobby groups to have pharmacy location and ownership
firmly on their agenda for inclusion in the new agreement.
If Pharmacy
is be relevant to community needs in the next five year agreement
period it must address the issues of choice now, and not wait
until the next agreement is in place. It is easy to brush this
aside with comments like "that is not part of the Third Agreement
and we will have to wait until the end of that before doing anything".
Now is the time to act. The start of the Fourth Agreement is only
two years away next week.
*
Function of the pharmacy in a remote health clinic.
The next boundary
is the function of the pharmacy in a remote health clinic.
Every clinic has a "pharmacy".
"There
have been considerable changes in the modes of delivery for primary
health care services, including pharmacy. (Since the early 1990s)"
NCP Review Pharmacy Regulation
The mode of
delivery of primary health care services has to change in Aboriginal
Health because the 1990s model has not worked. Morbidity got worse,
life expectancy was lowered again, and diabetes and renal disease
reached epidemic proportions. And where was pharmacy - still having
prescriptions dispensed at a distant hospital with the dispensed
product turning up two weeks after the doctor consult.
The Tiwi model has shown that prescriptions can be dispensed on
the same day as the doctor is seen and dose administration aids
can be ready in the form of Websterpaks when the patient needs
them. They do not have to wait 2-3 days while a grubby dosette
box is hosed down and refilled for the next week - half of which
has gone at any rate.
*
IT system to suit patient needs
The Tiwi dispensary
and inventory control system has been built with the assistance
and at no charge to the Tiwi Health Board, by Gerard Stevens from
Webstercare.
It emerged from a need to know:
* What was being taken from the "pharmacy?"
* Who was taking it?
* Who were they giving it to?
* What directions were being given in the supply?
* On whose authority was it being supplied?
All basic information that should be recorded for the supply of
any schedule poison to a patient when required by the Poisons
Act.
It is no use devising systems that either will not work - as in
the case of asking for things to be written down, or that are
beyond the immediate need of improving a patient's health.
So far this has worked and we now have a system operating at Nguiu
on Bathurst Island which meets the patient needs and conforms
to the law.
It also meets the requirements of the professional indemnity insurance
taken out by the Tiwi Health Board that would otherwise be void
in the event of a misadventure.
I compare what we have done in less than two years with what the
NT Department of Health has failed to do in six years - and that
is build a satisfactory IT system for remote health clinics.
PCIS started as RHIS in 1997 and is still not completed or installed
in the NT apart from one or two test sites.
The pharmacy component specs were given to me to look at in the
middle of last year. I got to page 17 of 35 in my comments and
ran out of time to complete my analysis of the very detailed proposal.
To establish a system without staged field testing to me seems
pointless.
The bigger it gets the harder it will be to bring to completion
and this add on to the PCIS system to my knowledge has yet to
see the light of day.
*
Development of indigenous talent through training
When the project
first started I thought it would be Aboriginal Health Workers
(AHWs) that we would be recruiting for pharmacy technician type
work. AHWs have grounding in pharmacy and would have been able
to specialise in a pharmacy stream. However due to a shortage
of AHWs this was not possible and we decided to recruit people
from the communities who were keen to learn.
This has proved successful with girls such as Linda showing that
the process will work in exactly the same way as it does in mainstream
community pharmacy. Girls with no previous experience are trained
as pharmacy technicians.
The training however has been a problem.
The course for Certificate III in Health Service Assistance (Hospital/Community
Health Pharmacy Assistance) does exist in the Health Training
Package but has not been delivered. An RTO is needed to do this
but first must come the resources for teaching and the development
of course material.
While this is not a difficult task it is beyond the resources
of the Tiwi Health Board. All efforts have failed to deliver this
important tool and it is to be hoped that the ANTA and the CSHTA
will find the money to contract someone to assist in this area.
If we are going to seriously upgrade the way pharmacy is practiced
we have to ensure the training is in place. I suggest this be
done by actioning the Certificate training for Pharmacy Technicians
and not try and burden the AHWs with any more duties that detract
from their clinical role.
*
Linda's Presentation
At this point, Linda gave her presentation about the pharmacy
at Julanimawu Health Clinic - then and now. (Editor's
note: we unfortunately do not have access to her notes to
reproduce here. She is pictured below involved in a pharmacy procedure)
*
Why successful
*
Full support of Tiwi Health Board to be different
The Board
has been fully supportive and from the outset has been enthusiastic
to make the pharmacy upgrade project work. Without their support
none of this would have been possible.
*
Clever use of PBS Approval Number for own pharmacy operation
The rule under which we were granted an Approval Number was a
new one for remote locations 10Kms from an existing pharmacy and
it did carry with it a "Start Up" allowance of $100,000.
The location must be in the ARIA 6 remoteness category.
*
Ability to use PBS through Section 100 arrangements for remote
Aboriginal health clinics
Whilst PBS prescriptions written under Section 85 are dispensed
through the Nguiu Pharmacy its main activity is to supply the
three Tiwi Islands health clinics with their PBS requirements
using the special arrangements under Section 100 of the National
Health Act for remote Aboriginal community health clinics. By
doing this the Tiwi Health Board is able to profit in the same
way as a retail community pharmacy but use that profit towards
improving the quality use of medicine.
We now employ a pharmacist who is responsible for the direction
of pharmacy services to the three Tiwi health clinics.
*
Fortunate liaison with Webstercare Australia (Gerard Stevens).
The alliance we have been able to forge with Webstercare through
Managing Director Gerard Stevens has been most fortunate. Gerard's
interest stemmed from his desire to find an alternative to the
dosette box for Aboriginal clients of the Ngannayatjarra Health
Service in the western desert of Western Australia,. The innovative
"clamshell" pack was the result. I had contact with
Gerard early in the project and he developed a personal interest
in what we were trying to do.
The outcome of all this was the dispensing and inventory control
software program now being marketed by Mirrijini, along with the
Webster-pak range of products.
Without the dedication of Gerard to our cause we would not be
anywhere near the stage of completion of a good pharmacy practice
model we have today.
*
Persistence in the face of adversity
It is true to say that we have been "up against it"
with all the official pharmacy organisations with an interest
in the supply of pharmaceuticals in the Northern Territory.
The Pharmacy Guild opposed
*The granting of the Approval Number.
*The owning of a pharmacy business by the Tiwi Health Board
The Pharmacy Board has given no encouragement and indeed
has sided with local pharmacists who have derided our activities
with misinformed criticism.
The NT Department of Health has been detailed in its examination
of procedures following "complaints" from local pharmacists.
However the Health Insurance Commission has been supportive
and encouraged our innovative approach.
Through all this we have had a single minded determination to
succeed.
I have been given great support by the Tiwi Health Board and especially
it's CEO Bill Barclay.
Without his commitment to change this would not have happened.
In conclusion I would like to leave you with these thoughts:
Aboriginal health is like a carving knife:
The blunt
side of the knife is the safe way of living but it is never used
The sharp side is where all the action is:
* Over consumption of alcohol and Gunja
* Domestic violence
* Physical and emotional stress
* Poor diet and little exercise
* Low maternal age
* Child upbringing creates pressure on all
* Disposable income goes quickly
Some is poor diet, no exercise and
The COAG Senior Officers report on the recommendations of the
NCP Review stated:
The Review
identifies benefits that might ensue from a revision of the regulation
of pharmacy location rules. Thorough examination of these issues
over the next five years would prepare the way for revised arrangements
to be implemented through the next Australian Community Pharmacy
Agreement.
I suggest
that to improve QUM to remote Aboriginal communities we need now
to make our views known on the benefit of ACCHOs owning their
own pharmacies.
Pharmacists in charge with access to PBS claiming will produce
the revenue to allow change to happen.
Too often we are put off a path for change because of a perceived
conflict.
In Aboriginal health we must face that conflict and bring about
change - there is not the time to wait for someone else to do
it.
Thank you
for the opportunity for us to present our case.
Rollo Manning
Tiwi Health Board
GPO Box 4347
Darwin NT 0
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