Last year I was in a Pharmacy News a couple of times. The second was on Australian Pharmacists using social media. While many use Facebook there are very few of us also using Twitter, running a blog and using other social media sites actively. The first article was about pharmacists working in remote areas. I guess that includes me.
They have kindly allowed me to reproduce the articles. This is the article on remote pharmacy.
Andrew Roberts lost his real name on his first day in his new job “out bush” as a remote area pharmacist. His workplace spans a quarter of a million kilometres in Central Australia — and there, for the last four years, he’s been known simply as “Robbo”.
When he first introduced himself as Andrew, the local Aboriginal health worker responded, horrified, “That’s a Kunmarnarra name!”
“I had not considered that Andrew might be a truly horrible name before this day,” Robbo recalls, explaining that Kunmarnarra refers to a similar-sounding name to that of someone who has died — and in the local culture, the name cannot be used.
Not wanting to be known as “Mr Roberts”, he’s been Robbo ever since; throughout the area served by the 11 clinics of the Ngaanyatjarra Health Service (the Aboriginal Community Controlled Health Organisation which employs him), to hospital staff, Government bureaucrats and pretty much everyone he meets.
From that significant first encounter onwards, Robbo reckons that each day he’s learned at least as much about Aboriginal culture as he has been able to teach his indigenous patients about “white man’s health”.
Working with indigenous people in remote health involves a big cultural shift for white health workers as well as their clientele, he says.
“A chronic condition that might get managed very well in a suburban white population raises a whole lot of cultural issues with disease management in indigenous communities — and you really have to listen and understand where they are coming from,” he explains.
Robbo is clearly pretty good at explaining his role, as evidenced by a coterie of international fans who comment regularly on the stories, photos and videos of outback life that he publishes via his blog, www.bitethedust.com.au.
But he reckons the best person to ask about his work is Fran Vaughan, the force behind his employment with the Ngaanyatjarra Health Service.
Vaughan: the pilot
Vaughan’s first visit as a pharmacist to a remote Aboriginal community was more than 20 years ago, and for the last eight years she’s provided visiting pharmacy health services to several different Aboriginal health services.
But her main role is as a remote pharmacy academic at the Centre for Remote Health; she also teaches pharmacy at Charles Darwin University.
In 2005, Vaughan helped to set up a one-year pilot project to test-run a model of full-time pharmacy services within a remote Aboriginal health service.
“We obtained a grant for the project which would cover the salary of a pharmacist employed by a health service, plus some funds to run an evaluation,” she says.
That’s where Robbo came in.
“He was employed for a year to start with. It’s not a long time to make a difference, really; but by the end of the 12 months, he was starting to educate staff, he was starting to crack the surface with clinical services,” she recalls.
“What we hadn’t predicted was that he would actually save money,” she adds.
“Before, a clinic nurse would put an order in, then a locum would do another order — but Robbo went in and cleaned everything up, standardised the impress list across all the different clinics, got rid of expired stock, developed guidelines for ordering; and even over a six-month period, the spend on drugs went down quite significantly.”
After the first year, the health service concluded that the clinical input of a pharmacist was really valuable, and funded the position permanently.
“It was only when they actually experienced a pharmacist’s work that the health service realised what they had been missing out on, because nurses generally do all the dispensing and the doctors can check the drug interactions,” she says.
But Vaughan believes dispensing is barely on the radar in the role of the pharmacist in remote health — and cleaning up a drug room is just the start, she says. Education, clinical advice and on-site home medicines reviews are where the real value lies; and having a pharmacist on staff improves the skill of everyone else on the team. And, she adds, it needs continuity to be effective.
On Robbo’s hard drive
I ask Robbo to describe his average day and he laughs — there’s no such thing. He covers more than 50,000km a year, driving between health clinics in his dusty troop carrier. The roads are hard; an average thousand-kilometre round trip often involves a couple of hours by the side of the road helping someone whose car has broken down.
With 11 health clinics to service, spread out over a vast area, it’s impossible for Robbo to provide a traditional, on-site dispensary function, so each clinic still sources drugs from an Alice Springs pharmacy and the clinic nurses then supply individual patients.
Robbo provides education and information for health workers at the clinics and their patients, and he also keeps on top of the processes for ordering, storage and supply —a critical role in an extreme environment where power supplies are unpredictable.
While valuable information can (and does) come from looking at population statistics in his office, Robbo says there are great advantages in having a pharmacist sit down and talk with patients about their medications and disease states — and out bush, talking takes time.
“Even though I’ve been out here for so long and I’m quite well-known, it still takes a day or two to build up a rapport in communities,” Robbo says.
He will run education sessions on topics such as medication for diabetes and other chronic conditions for patients, or information sessions for clinic health workers as well as home medicines reviews.
“I might sit down with someone’s family group to talk about their medication. Yes, it throws patient confidentiality out, but often someone who doesn’t speak English will invite their whole family around; it’s good because it means the disease states are understood by the family a lot better, and they will support things like making sure the person keeps taking their medication, even when they’re not feeling sick.”
While the challenges are enormous, he sees the most significant value in his role is the continuity of care he gives the people in his communities.
“In our northern-most community, it was only 1984 when the last mob walked in from losing their traditional way of life. There’s a totally different understanding of health and language, of health literacy. You can only achieve change with consistent, repeated visits and discussions.”
And that change is desperately needed. Health statistics show little improvement in Aboriginal health despite decades of programs and promises. The most recent government report on the subject, the December 2008 Interim Report of the National Health and Hospitals Reform Commission, acknowledged the “inequitable health outcomes and access to health services” for indigenous Australians and the need for universal entitlement to medical and pharmaceutical services under Medicare.
A statistical overview published by the Human Rights and Equal Opportunity Commission in 2006 showed that the average life expectancy for indigenous men is 60 years, 65 for indigenous women — that’s about 17 years less than life expectancy for non-indigenous Australians. Aboriginal people have almost 10 times the rate of diabetes and three times the rate of heart disease as other Australians; infant mortality rates for indigenous babies in the NT are more than three times the national rate.
Risk factors are higher; obesity affects around 28 per cent of indigenous adults, compared to around 16 per cent of non-indigenous; and 49 per cent of indigenous adults smoke compared with around 24 per cent of the general adult population.
Second-class PBS
Robbo believes he’s the only pharmacist in Australia living and working in an indigenous community, although there are many supplying medications and consulting in indigenous health.
“Most pharmacists in indigenous health are doing Section 100 support, which is a supply service, not a service where you work with indigenous people full-time,” he explains.
Under Section 100 of the National Health Act, remote Aboriginal and Torres Strait Islander Health Services can order PBS medicine in bulk through retail pharmacies and dispense as needed to patients. The dispensing usually occurs without direct involvement of a pharmacist and there is no charge to the patient.
After many years of working within the system, pharmacist and lobbyist Rollo Manning is convinced that the existing infrastructure supporting PBS delivery is inadequate.
“Look, medicine without information is just a bottle of chemicals,” he argues.
“There’s no line of communication between the pharmacist supplying the medicine and the Aboriginal person in the community who goes to the health clinic and gets one of those packets of medicine,” he says.
“Straightaway, you’ve got a huge difference in the way the PBS is delivered there compared to the urban setting.”
Pharmacists providing a PBS medication to a remote community health clinic are paid a dispensing fee of $1.14, a fraction of the $6.00 PBS dispensing fee paid in a direct retail pharmacy.
Manning believes that the huge saving in dispensing fees to the government (he estimates it at well over $1.5 million in the NT alone) creates a second-class PBS for Aboriginal people in remote places.
“With the $1.5 million the Commonwealth saves on remote dispensing fees, we could employ quite a few pharmacists to go out to those communities and explain to people what the hell they’re getting the stuff for,” he says, adding that to his knowledge, Robbo is probably the only pharmacist in Australia employed by a health service to do outreach work in remote health clinics, rather than simply dispense medication.
In most parts of Australia, pharmacy (like the rest of the health system) targets middle-class, well- educated people who already have a pretty good idea of how to stay healthy, Manning says.
But, he says, pharmacies that supply remote indigenous communities need to be looked at as part of the primary health care system — rather than “a shop somewhere that puts stuff in a box and ships it out.”
New speciality needed
Professor Patrick Ball took up the Foundation Chair of Rural Pharmacy at Charles Sturt University in Wagga Wagga in 2005. A year later, he travelled with Rollo Manning to visit various outback centres in the NT, calling in on a number of remote Aboriginal health services. Ball had come from the UK and New Zealand, where he had many years of experience with multidisciplinary teams working in hospital support, and was accustomed to remote dispensing.
But he admits he was shocked when he saw what really happens with drugs dispensed to the Aboriginal health clinics.
“What really struck me was how little pharmacy was really involved. There’s an awful lot of packing of Webster packs and supply functions and so on, but little support in terms of medication adherence —actually getting people to take their medicines,” he says.
He said health workers estimated that only 10 to 20 per cent of the Webster packs prepared for the remote clinics were collected by patients; the rest were eventually shipped back to the pharmacy.
Many patients with chronic diseases had multiple medications which in city health services would usually involve pharmacists making regular interventions with doctors and other health professionals, he says.
“In these centres, there’s a real need for the involvement of somebody who can speak the local language,” Ball says, describing a need for a new type of Aboriginal health worker, a medication compliance health specialist.
This role would involve an indigenous person who speaks the local language who has pharmacy training in medications, particularly for chronic disease states.
Ball says several programs currently in place for indigenous communities in Kenya, Nigeria and Malaysia could provide a model for programs that would work effectively in Australia.
In traditional Aboriginal culture, there’s little understanding of chronic disease and little incentive to take medication when the patient may be feeling well — making the cultural transition to long-term disease management needs the involvement of a person who can cross the language barrier, he says.
At the same time, there will remain a need for qualified pharmacists in outreach positions to support such Aboriginal health worker posts through ongoing follow up, refreshers, training in new disease states and new medicines and there will be scope for pharmacists to be involved in home medicine reviews.
Highest need, worst shortage
The need for pharmacists in indigenous communities where chronic disease is rife is starkly apparent — yet there’s an alarming shortage.
The Australian Institute of Health and Welfare (AIHW) reported in 2008 that the rate of employed pharmacists nationally was lowest in areas where more than 20 per cent of the population was indigenous, averaging 21 pharmacists for every 100,000 people.
Areas with less than one per cent of indigenous people in the population had more than four times as many pharmacists per capita, with 94 for every 100,000 people.
The same report revealed just nine indigenous pharmacy students out of a total of more than 4000 enrolled in undergraduate pharmacy courses in 2006.
Robbo says a vacant position for a community pharmacist in his region remains unfilled after months of advertising — and believes potential applicants are fearful of the unknown.
“The hardest thing for pharmacists working in indigenous health is they have to get out of their comfort zones, leave Darwin or Alice Springs or Adelaide, and do work where they’re not sitting in a pharmacy but they are out there on the ground.”
Hope on the horizon
While pharmacists are thin on the ground in rural Australia, and few indigenous people will graduate in coming years, there’s better news when it comes to pharmacy assistant roles.
The Government-funded Aboriginal and Torres Strait Islander Pharmacy Assistant Traineeship Scheme (ATSIPATS) reports a fivefold increase in indigenous pharmacy assistant trainees, with 27 traineeships approved since the assistance package was launched a year ago.
Some pharmacy training is beginning to address the issue, too.
Professor Patrick Ball now takes third-year pharmacy students on remote health tours where they visit Aboriginal health services clinics.
“On the way to Katherine, students are taken out by a guide who talks all about Aboriginal medicines and effectively shows them the medicine section of what they call the biggest pharmacy in the world,” Ball continues.
Students are shown natural treatments, such as the use of termite mounds for treating diarrhoea.
Ball says this part of the tour strongly demonstrates the cultural divide between traditional medicine, which to indigenous people seems to have a real, meaningful explanation and origin, and the “white man’s medicine”, which isn’t well explained and is often associated with hospitals where their relatives may have gone — and then died.
Fran Vaughan believes remote area pharmacy is in its infancy, and compares it to the early days of clinical pharmacy in hospital wards, around 30 years ago in Australia.
“Clinical pharmacists started out really having to convince people that they could fulfil a need; now, in any major hospital, pharmacists are just accepted as part of the scene — they have developed standards of practice, formulas for how many beds per pharmacist and so on.”
Vaughan believes that training indigenous health workers as technicians or “medicines workers” to provide basic dispensing services in remote communities could be very beneficial. But, she points out, it’s difficult to justify training when there are currently no positions for such medicines workers, and it’s difficult to argue for such positions when there is no training.
She’s hopeful that the introduction of a new third-year unit, Rural and Remote Pharmacy Practice, which she co-teaches in the undergraduate pharmacy degree at Charles Darwin University, may be a watershed.
“Our first graduates will be out this year, so it will be very interesting to see how many go back and work in indigenous health.”
Island hopping for health
Lynn Short bought the Thursday Island retail pharmacy about a decade ago and her clients include the island’s residents, plus another 20 small health clinics in outlying islands.
“We’re the only pharmacy for about 1000 kilometres,” she says.
Much of her work is supplying medications to the health clinics and to local indigenous people under Section 100 arrangements and providing clinical support.
“In the beginning, I used to fly around the Straits clinics with a medical team on a plane — there would be doctors and midwives and podiatrists and the optometrists,” she explains.
Short had just four hours to spend at remote clinics and the staff were kept busy with other professionals, so her role was limited to sorting the dispensary.
She has since bought a boat, and with her partner (a boat captain) she now visits each clinic for a full day without other medical teams visiting.
The morning is spent tidying and date-checking stock. “After lunch is my quality time with the health centre staff. We have education modules that we create and we trade with other pharmacists, because nothing exists, so we make our own,” she says.
Visiting each clinic twice a year means two months at sea because it takes a month to get around to each of the twenty clinics. But between visits, remote clinic staff constantly phone and email her four staff pharmacists.
Of her 20 staff, 15 are indigenous. “A lot of our people are second-language English, so it’s terribly important for both the cultural benefit, but also to actually communicate properly.”
Short says proudly that when the ATSIPAT scheme was first released a year ago, 10 of the first 12 applicants nationally were her employees.
“I’m down to six assistants now, but I expected that,” she says, adding that the long commitment can be difficult culturally for many indigenous people.
Short also has indigenous staff who have privately obtained their pharmacy assistant qualifications, she says. “Judy is a grade four and qualified about 10 years ago, with her full dispensary tech.”
The ATSIPAT program will help Short build a pool of trained, experienced staff to handle growing demand for blister-packed medications.
Her pharmacy business even has a dedicated staff training area (which often doubles as a nursery for staff with very young children) and Short flies Guild trainers up for a few days at the beginning, middle and end of each grade.
“I’ve seen my staff come and go, but they come back,” she says, adding that many Islanders move to the mainland for a few years but then return; and when they do, “They will be trained and I’ll be ready for them!”
Remote placement ignites a spark
Elise Taylor is doing her honours year as a Bachelor of Pharmacy student at Charles Sturt University in Wagga Wagga, after completing a placement in Alice Springs.
Originally from the city, Taylor became enthused about the idea of working in remote indigenous communities when she travelled to remote communities as part of Professor Patrick Ball’s course.
She says that she learned an enormous amount while on placement in Alice Springs, where she worked with a retail pharmacy and with an Aboriginal health care centre with a multi-disciplinary team that included pharmacy.
“Diabetes and blood pressure management were the two most common health conditions for Aboriginal people,” Taylor says.
A recurring issue for indigenous patients was non-compliance, she says.
“A condition of the free Webster packs was that people had to bring back their old ones, and a lot of the time, they might not have taken their medication; or they were selective, they may not like the big pill for their diabetes but don’t mind taking the little ones for their blood pressure.”
Taylor says that she was surprised by the language barrier; English was a second or third language to a lot of her clients, and often they were too shy to speak to her.
Many of the patients at the Aboriginal health care centre didn’t have a formal address, she says; and because of their beliefs, they may not have a consistent name.
“It was very much a case of trusting the patients and looking at the dose that they’d brought back last time to identify who they were in the system,” she says.
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