National President’s Message: COVID-19 Update
21 April 2020
I want to start by congratulating you and your families for your sacrifice and discipline during this unprecedented global pandemic. This week we have started to not only see the curve flatten, but community transmission all but fall away. Without being complacent, Australia is arguably in the strongest global position to defeat the virus, but the economic impacts of which will be felt for decades.
You continue to amaze me for your resilience, dedication to the profession and community and ability to care. The rate of regulatory changes from all levels of Government continues at a frenetic pace and it can be understandably difficult to keep up. The last seven days saw the introduction of telehealth medicine review services, follow-up visits for HMRs/RMMRs, changes to pharmacist vaccination and regulatory changes at state/territory level for digital image prescriptions.
In this week’s column, I want to work through a number of these changes with you to help reduce confusion and keep you informed on how we are working to help reduce some of the pain-points you are constantly experiencing in your daily practice.
Changes to medicine review services
I open this week’s President’s message with two significant announcements relating to medicine review services. The first is the announcement that Government will fund pharmacist delivery of medicine management reviews via telehealth. The second is the introduction of up to two follow-up consultations for HMRs and RMMRs, where needed by patients, to help manage medicine-related problems.
6CPA medicine review program services can now be delivered by telehealth to eligible patients. These services include HMRs, RMMRs, Medschecks and Diabetes Medschecks. Subject to eligibility criteria (which includes the vast majority of patients) patients can start accessing these remunerated pharmacist services through video or phone consultation from today.
To support you in these changes, we have developed resources to help you conduct these services in a new delivery mode. You should particularly be aware of the privacy and encryption levels of the tools which you use.
AHPRA and the Department of Health have reminded health professionals delivering telehealth services that many free platforms do not have adequate encryption for delivery of health services. The Department of Health notes telehealth can be provided through video calling apps and software such as Zoom, Skype, FaceTime, Duo, GoToMeeting and others.
I cannot tell you how hard PSA staff and elected representatives have fought for these changes. The outcome of this work is that from today you can pivot to providing these services in a new online format for those patients who are eligible, often vulnerable, and who need these services.
I will be facilitating an upcoming webinar on telehealth and electronic prescriptions where we will be able to provide you with practical guidance on digital health advancements during COVID-19.
Follow-up consultations: HMRs and RMMRs
Today is momentous as it marks the start of remunerated follow-up visits for HMR and RMMR services. Follow-up consultations means patients can receive additional review services to help resolve complex and multifaceted medicine problems after the initial review.
Follow-up consultations are essential in supporting a more effective cycle of care and helping pharmacists be more effective in resolving medicine safety problems. With 250,000 hospital admissions each year due to medicine-related problems, the safe and quality use of medicines is more important than ever.
PSA has updated the practice guidelines to support and reflect current best practice when providing these services:
- Guidelines for Comprehensive Medication Management Reviews: including new guidance for HMRs and RMMRs on considerations for recommending and undertaking follow-ups after the initial review, support for collaboration and communication with the healthcare team and describes the role of pharmacists as part of this team when providing medication management review services.
- Guidelines for Quality Use of Medicines (QUM) services: best practice guidance for pharmacists providing QUM services in residential aged care facilities. Be guided on how to plan and undertake QUM activities that form part of a QUM Plan and contribute to continuous quality improvement.
The guidelines have been developed with funding provided by the Department of Health.
These funded follow-ups have been the subject of many months of discussions between PSA and the Department of Health and the Health Minister. I have long advocated for a system that allows for medicine reviews to be conducted frequently that is dependent on patient’s needs, with meaningful follow-up and I commend the Government for making this necessary change.
Digital image prescriptions
Digital image prescriptions remain a challenge. This important initiative to enable telehealth medical consultations remains haphazard and burdensome in its implementation.
Where are digital image prescriptions legal?
The past week has seen South Australia, NSW and Tasmania join Victoria and WA in making regulatory moves to enable lawful supply of prescriptions from an electronic digital image.
ACT Health advised our members in Canberra late last week that digital image prescriptions fall within existing ACT poisons regulations. In the Northern Territory the ability to supply medicines off electronic image-based prescriptions is enabled under existing legislation.
This leaves Queensland, alone, as the only jurisdiction in which digital image prescriptions are not currently permissible. PSA understands that enabling regulation in Queensland is currently being held up due to advice that the measure requires an act of Parliament.
The state and federal interface always causes confusion – and it is unsurprising that confusion is rife at a time in which changes are happening so quickly. But what I am hearing, loud and clear, is that you are wearing an incredible administrative burden from this confusion, often in the time-consuming role of communicating government regulatory changes to medical colleagues.
I am receiving reports some prescribers and their staff are:
- sending prescriptions as digital image prescriptions and then sending the originals to the pharmacy; the original hard copy prescription must be retained by the prescriber for compliance and audit purposes.
- refusing to supply original prescriptions for medicines not eligible for supply under the arrangement (e.g. Controlled Drugs (most states)); prescribers are responsible to ensure phone/fax orders (i.e. prescription owing) are dispatched to you without delay.
- requesting pre-paid return addressed envelopes to supply original prescriptions to pharmacies.
- requesting you send staff to collect prescriptions at their clinics.
However, most of all, I’m receiving reports that this is becoming a point of friction with prescribers at a time it is more important than ever we all work collaboratively to support and facilitate the safe supply of medicines.
Risk in unannounced changed: NSW and S4D
In introducing digital image prescription arrangements last Friday, NSW Health added five new substances to S4D (pregabalin, quetiapine, tramadol, zolpidem and zopiclone). Given their potential for abuse and diversion, this change made a lot of sense and is welcome.
What didn’t make a lot of sense was to effect this change on the day it was announced, in effect ripping six months off the expiry date for these prescriptions overnight without warning. These changes were a surprise and not included in the announcement for digital image prescriptions the weekend prior.
In failing to announce this change in advance:
- Patients on long-term stable therapy (particularly quetiapine and pregabalin) may have been left overnight without a valid prescription requiring them to see a doctor immediately to arrange ongoing therapy
- Those of you in NSW were in a dangerous position where you may have been completely unaware of this change and likely to have unwittingly supplied medicines outside of its validity period.
We have worked to quickly communicate this change to members via our microsite and social media. PSA continues to work with NSW Health to help communicate these changes to the profession and more wisely to ensure both yourselves and prescribers are aware of these changes and not exposed to professional risk.
Demonstrating the need for pharmacist expertise in government
The genesis of confusion was the Government factsheets which did not effectively communicate that state and territory regulatory changes were required prior to supplying of medicines under this arrangement become lawful.
While developing sound policy implementation is difficult in this rapidly evolving environment, it is unlikely this oversight would have occurred if an Australian Chief Pharmacist existed within the Department of Health which signed off on the information. I will continue to raise this with the Department in my meetings with officials.
PSA’s teams around Australia are in regular contact with Health Departments to help clarify details on these interim arrangements to help inform members around the country. To help you keep track of the plethora of changes affecting your practice, we have rejigged the way we present this information on PSA COVID-19 microsite.
From today, state-specific regulatory information is available side-by-side with PBS eligibility requirements for special arrangements such as digital image prescriptions and continued dispensing. You can find it here.
I trust this will make it easier to find critical information quickly when you need it. I would value feedback, as there is the potential to expand this format to other areas of pharmacy practice (vaccination, opioid replacement etc.) Our microsite will continue to be updated daily, and I will continue to keep you informed of major changes through my weekly email and PSA’s social media channels.
In my email last week, I raised the fact that I have heard from a number of pharmacy interns in regard to their concerns about completing their required hours should they have to go into quarantine or self-isolation.
Interns have particularly communicated to me a fear of the potential for repeated 14-day self-isolation periods following potential COVID-19 exposures, and the stress associated with how this impacts on their required intern hours or even ongoing employment at the end of the year.
I understand these fears. There is a real potential that any of you may be required to self-isolate for 14 days multiple times during the pandemic. I have raised a number of issues on your behalf directly with the Australian Pharmacy Council and the Pharmacy Board of Australia. I have asked for urgent review of the requirements this year to provide the flexibility and certainty that you need.
While there is nothing to announce yet, I am confident am confident there will be changes announced shortly to help you satisfy the requirements of general registration within the regular 12-month time frame. It concerns me that there is not the clarity required that you need in a time of higher than usual stress levels, and that this might exacerbate mental health concerns of our intern pharmacists.
Rural and remote Australia
During the week, PSA CEO, Mark Kinsela, attended the Rural and Remote Health COVID-19 meeting with the Federal Minister for Rural Health Mark Coulton. It was welcome to hear the minister specifically recognise pharmacists for the great work that you are all doing in your communities.
In addition to state and territory government testing centres, the Government is supporting the establishing of respiratory testing clinics including eight in rural and remote centres. These are being delivered through the PHNs and you should make yourself familiar with the testing facilities available for you, your patients and your staff in your local area.
The Government remains focussed on supporting the mental health of rural Australians, including the health workforce. The Government has supported resources to support your mental health well-being. Up-to-date links for support can be sourced via our microsite.
The minister also outlined the Government is looking at investing further resources to support locum services, including greater flexibility for access. In a sensible measure for rural and remote Australia, the ACCC has provided flexibility to pharmacy wholesalers who have been provided exemptions to coordinate medicine distribution during COVID-19. The minister also outlined ongoing monitoring of medicine supply chains, and reported a stabilisation of supply in recent weeks, which is consistent with reports from those of you in rural and remote area.
During the meeting, Mark raised a number of issues of concern directly with the minister, including:
- Access to PPE and medicines supply issues in rural and remote pharmacy
- Need for support and planning for single pharmacy towns to ensure continuity of access to medicine should key personnel be required to self-isolate due to infection or exposure to COVID-19
- COVID-19 testing for pharmacy staff
- Challenges with pharmacy interns – pharmacy closures, isolation, and preceptor access.
We are attending these meetings weekly and will report back to you progress on these issues. Being in these meetings and able to raise concerns directly to the minister is helping us to achieve timely and pragmatic solutions to the problems you, in our rural and remote communities, are facing.
As I reported last week, the direction the initiative has taken is not acceptable and therefore we cannot support it without significant change.
I will continue to work on your behalf with Government to work towards a model of therapeutic substitution during out-of-stock situations which actually works, and which recognises the skills and knowledge of pharmacists. It shouldn’t be this hard. It is in your capability and you can certainly be trusted to work out that 2 x 250mg tablets = 1 x 500mg tablet.
Risk of complacency
The continued reduction of daily COVID-19 notifications is extraordinary in the context of the global pandemic progression. Australia’s strong infection control response and island advantage has seen the curve flattened beyond our most optimistic prediction.
This has led to agitation from some Australian voices to relax our physical distancing and ‘Stay at Home’ directives, and risks community complacency in vigilance against COVID-19 exposure.
I endorse the sentiments of population health experts and chief medical officers in reinforcing the ongoing importance of physical distancing and Stay at Home directives. As health care ambassadors, it is important that you and your staff continue to reinforce these messages with your patients and support them to continue to access pharmacist care consistent with these recommendations.
- Actively encouraging delivery and contact-free options for people over 70 years who should be self-isolating at home
- Discouraging people who are unwell from entering a pharmacy
- Encouraging people with fever or acute respiratory symptoms to seek advice and testing for COVID-19
- Encourage and demonstrate physical distancing in the pharmacy
There are positive signs however the community must remain vigilant. One aspect of this is the overwhelming demand for influenza vaccine we have already seen. I welcome the Health Minister’s recent announcement of an additional 3 million influenza vaccines available to Australians through community pharmacy and GPs in the coming months.
We are continuing to work with Government to ensure there is adequate influenza vaccine supply in Australia and we have been assured there are nearly 8 million vaccines for the private market this year, up from close to 7 million vaccines last year.
Last Wednesday, I was joined in our webinar by PSA’s new General Manager for Policy and Engagement, Chris Campbell. The webinar focused on the best way to set up your pharmacy or pharmacy practice to accommodate the changes and new ways of working to protect you, your staff and your patients during COVID-19.
This practical topic created intense interest and positive feedback and I would like to thank Chris for joining me and answering all your questions.
COVID-19 has shown us the damaging impact which stigma can have in our society. In this week’s webinar, we focus on the issue of stigma through the lens of Hepatitis C in the second instalment of PSA’s ‘Facing Up To…’ series.
Jarrod McMaugh MPS will talk with a person living with Hepatitis C to help us see the impact and effect of stigma through their eyes. They’ll discuss barriers to treatment, stigma, and the importance of testing, contextualised within what can be done during COVID-19 isolation measures to limit the spread of the disease and support patients living with the condition.
Help face up to the stigma experienced by people living with Hepatitis C. Bring the questions you’ve always wanted to ask but were too scared to. This is your opportunity to hear someone speak openly about their lived experience of Hepatitis C and the stigma that surrounds it in a safe environment.
The webinar will be run twice (7.30PM EST and 9.00pm EST) so as many of you as possible can join the conversation.
Our dedicated COVID-19 website is continually updated with the latest information that you need to be supported while you care for the community during the COVID-19 crisis. There are series of FAQs on the website and can be found here.
Your PSA team are working hard to keep you informed and support you during the pandemic. Keep feeding back the issues and concerns which you are working through to help us help you. Please contact us at email@example.com.
Week-in and week-out you are showing that our profession is dedicated, reliable, dependable and worthy of the trust that our society places in you all. The pandemic and physical distancing requirements will continue to be with us all for some time and patients will look to you for reassurance and support. Never underestimate the value of a 30-second conversation or a caring word towards your patients at a time when they are struggling. The work you do every single hour and every single day enhances our community during this pandemic.
Associate Professor Chris Freeman
Pharmaceutical Society of Australia