Pharmacy Guild of Tasmania

Pharmacy Guild of Australia – Tasmanian Branch

Submission to Independent Review of the Response to the North-West Tasmania COVID-19 Outbreak

The Pharmacy Guild of Australia (the Guild) is the peak organisational body representing owners of community pharmacy through an annual membership subscription.  In Tasmania, the Guild represents approximately 80% of all registered pharmacies across the State. Those pharmacies, known as Section 90 and approved under the National Health Act, are required to supply Pharmaceutical Benefits Scheme (PBS) approved medications, acting as an agent for Government to ensure timely access to medications.

The Guild recognises the pandemic as an exceptional circumstance, requiring multi-level coordination across many Government agencies and other stakeholders, particularly in public health. The pandemic presented the Guild and its members with varying situations dependent on the areas of Covid-19 presentations, type and location of pharmacy and the capacity to maintain ongoing access of medication supply.

The response of the Guild, in representing our members, is to provide this Review with our view on events and how these events impacted community pharmacy and by extension, consumers of medication supply and services. The timelines provided outside of the North West outbreak are for context, to set the scene in terms of the initial early fragmented approach to inclusion of pharmacies in the pandemic planning and preparedness.

In the lead up to recognising the role of community pharmacy in an emergency situation we would like to highlight the Dunalley fires episode and the more recent Dover/Geeveston fires. Both of these events saw many people displaced and unable to access medications and in the case of the Dover/Geeveston fire the Guild sought clarification on the role of community pharmacy and what assistance could be rendered via various state agencies including Public Health and the Tasmanian Hospital Service.

We believe that there were areas of concern at this point regarding coordination of services, including medication supply and assistance by State agencies. We discussed these concerns with the Emergency Preparedness and Response Unit (EPRU) and requested that community pharmacy services be formally included in response plans and recognised in their role to maintain medication supply.

The following timeline is provided for reference:

• On 23^rd January, the Guild was receiving questions from members about the increased awareness of coronavirus, the risks and the potential to spread. We contacted the Senior Adviser of the EPRU who reached out to the Director of Public Health and were informed that information received would be added to the DHHS fax stream service with links to the Commonwealth site for sources of information.
• Information about masks and the use of masks was also being requested at this time; we received an email from Primary Health Tasmania (PHT) on 12^th February stating that the Federal Department of Health would release, via the PHTs, limited access to masks for pharmacists and staff.
• On 26^th February we contacted CEO of PHT and the Senior Adviser EPRU to enquire about the State response to this article appearing in the Sydney Morning Herald:
  
  “Virus emergency blueprint: Australia pulls trigger on pandemic plan
  The Australian government has activated its emergency response plan to an impending coronavirus pandemic, foreshadowing fever clinics, fast-tracked vaccines and severe pressure on hospitals, blood banks, medical supplies and mortuaries. Read in The Sydney Morning Herald: https://apple.news/AqGGz2ghkSZObvtXH6jEAzg” The response we received from the Senior Adviser (EPRU) stated that “There’s a lot of work currently underway to plan a health system response to COVID-19 for Tasmania.  It’s going to be tricky as the current risk to COVID-19 merges unavoidably with flu season.  Community pharmacy, and the role of community pharmacists, is being considered in local planning.”
  
  The bolded segment highlights the discussion regarding the role of community pharmacy, however there was no formal meeting with the Guild to discuss the role of community pharmacy in maintaining supply of PBS medications.
• On 5^th March, in an email again to the Senior Adviser and the Director of Public Health on we asked specific questions about testing and the response to members based on a Tasmanian approach, with the Senior Adviser (EPRU) noting that there were no formalised plans and the communication by Public Health Services was not getting reach.
• On 6^th March PHT reached out and organised a meeting between the Guild, the Pharmaceutical Society (PSA) Tasmania and representatives of PHS and EPRU to clarify areas of concern received from our respective members. We discussed Emergency Medication Access, essentially to enable people to access a one month supply of their normal medications without a prescription in the event that they are unable to attend regular visits with GPs.
• On 12^th March we received information (supplied by a member) from a local GP clinic in Launceston outlining testing access. This was contrary to information that we had received via PHS and we alerted EPRU.  EPRU had to undertake actions to remediate the misinformation which had been circulated on the GP Clinic social media pages.
• On the same day, the Guild supplied EPRU with the Guild policy on Medication Therapeutic Substitution, whereby in the event of medication shortages pharmacists are able to substitute formula and dose without the need for a change to a prescription.

The above exchange represents the difficulty we experienced in receiving clear and consistent messaging as to the role of community pharmacy. In a world where information transfer happens at a pace without precedent, it was vital for our members that we could provide them with trusted information specific to our State response. At this time GPs were writing regulation 49 scripts which meant that patients were receiving 6 month’s supply of medication - against clinical guidelines. This in turn placed huge strain on the medication supply chain into the State, where our natural sea border meant delays in access to medications.

From 15^th of March weekly teleconferences were organised with the Health Minister, the Hon Sarah Courtney MP, the Secretary of Health, Katherine Morgan-Wicks and the Director of Public Health, Dr Mark Veitch, along with representatives from PHT, medical, nursing, ambulance, pharmacy representative bodies, and various other representatives.  These teleconferences were very good in capturing and understanding the numerous issues across the health sector.

From a public health perspective, pharmacy as front-line essential workers, and their staff, were not recognised for priority testing and screening, nor were we able to easily access masks and PPE, though thankfully unlike Victoria, Tasmania has not had to undertake such stringent measures. There were no formal arrangements offered by the State to maintain pharmacy services in community pharmacies if pharmacists and their teams fell ill.

It should be noted that the support offered by the State Government in making a $10,000 grant available to members to undertake necessary operational changes in their pharmacies to respond to the pandemic was very welcome.

Medication supply management was the paramount message from the Guild to members; essentially to ensure that members were able to maintain ordered medication supply, except for influenza vaccines which were promoted via the CMO, resulting in an earlier than usual request for influenza vaccination services.

There was a disparate approach to influenza services, with a ‘turn a blind eye’ offered to doctors in the way they were able to offer immunisations to patients. “Car park clinics” were allowed for GPs, but not for pharmacists as State legislation required people to come into the pharmacy environment for a vaccination.

Pharmacies in Tasmania are approved to offer pharmacotherapy to treat patients with opioid addiction. These services are available in many pharmacies and considerable time was spent understanding the parameters for maintaining dosing services as required through Alcohol and Drug Services (ADS). The Guild initially sought a position from ADS for revised dosing regime in the event people were further restricted or required to isolate on 12^th March.

A final position on how doses would be managed with accompanying documentation, didn’t occur until two months later on 13^th May. There was a lack of clarity in understanding the practical approach required in a community pharmacy setting in addition to managing risks associated with delivery of doses to those required to isolate who may be considered ‘unstable’. This was of even greater concern in the North West Coast during the lockdown.

The North West Coast lock down, including closure of two hospitals, posed unique challenges to our members who operate community pharmacies in these regions. We received only brief communication from the Director of Pharmacy Hospital in relation to how outpatient prescriptions may need to be managed. Several of our members have long standing relationships with both hospitals due to opening hours and the transfer of patients and their medications between hospital community settings.

It was disheartening to see instances where members had offered to assist with medication continuance services, generally through supply of medication via ‘owing prescriptions’ (supplied at a later date) due to patients not being able to receive medications through hospital channels, along with delivery of those medications, were not recognised nor remunerated.

In fact, there are anecdotal instances of efforts to stymie the collegiate approach between hospital pharmacy employees and local community pharmacists in their attempts to manage patients and maintain medication therapies.

The timeline of events shown above clearly demonstrates the need for a coordinated response across the entire healthcare sector and for pharmacy to be recognised as an essential service.  Local communities rely heavily on the pharmacy and pharmacists in emergencies which can exert extraordinary pressures on resources and people.

The circumstances being dealt with by community pharmacy during the North-West Tasmania COVID-19 outbreak were extraordinary and, we believe, without sufficient support being provided by Public Service senior administrators who were not on the ground while events continually unfolded, requiring pragmatic approaches.

We are available to discuss our submission as required.

John Dowling

President, Tasmanian Branch

Pharmacy Guild of Australia