Australia is a big country and, with around 19.8 million people in an area one and a half times the size of Europe, most of it is pretty empty. The majority of Australia’s population can be found in a handful of coastal cities such as Sydney, Melbourne or Perth.
Sydney, which played host to this year’s International Pharmaceutical Federation (FIP) congress, is home to around four million people. With its sandstone Victorian buildings nestling among modern skyscrapers, and Queen Victoria gazing solemnly across George Street, you do not feel as if you are 12,000 miles from home. For those who have a fondness for old-fashioned British food, there are steak and kidney pies in abundance, not to mention fairy cakes topped with white or pink icing. And, yes, they do taste exactly like you remember. Not that Sydney is predominantly British any more. With its large population of Asians, particularly Vietnamese, together with Italians, Greeks and other groups, it is a modern, multicultural city. And if you love being on or in the water, there are probably few finer places in which to live and work.
Australian health care
Australia is a federation of six states and two territories. It has a commonwealth (federal) government and state and local governments. Not surprisingly, the Australian health care system has its origins in the British system (albeit before the National Health Service) although, during recent years, it has also been shaped by the American system. With a spend of around A$60 billion a year, (£1 is approximately equal to A$2.5) the health care system accounts for 9 per cent of the gross domestic product (which is a little higher than ours). The system is administered by both the states and territories together with the commonwealth government.
Health care is funded partly through a health insurance system (Medicare) the money for which is collected via general taxation. Medicare is designed to ensure open access to public hospitals and both general and specialist care. Private health insurance is also available for those who may prefer treatment in a private hospital.
Hospital admission rates are among the world’s highest, but they are falling. As in the United Kingdom, waiting lists exist for elective surgery in public hospitals, but emergency care is generally good. Visits to general practitioners can be charged to Medicare on a “fee-for-service” basis. Some GPs charge the full fee and patients then seek reimbursement from Medicare; other GPs bill Medicare directly.
Australians generally enjoy good health with life expectancy at 75 years for men and 81 for women. Despite the fact that 40 per cent of the country lies in the tropics, tropical disease such as malaria, yellow fever, cholera and typhoid are almost unheard of, although other mosquito-borne diseases such as dengue fever, Ross River fever and Murray Valley encephalitis occur in northern Australia.
The notable exception to Australia’s positive health picture is that of the indigenous people (the Aboriginal and Torres Strait islander people) of which the estimated population is about 372,000. Many reports paint a depressing view of the health of the Australian Aboriginal. Although infant mortality has improved it is still almost three times higher in the indigenous population than in the total population.
In 2000, the average age of death for indigenous Australians was 25 years lower than for the population as a whole. This gap in life expectancy is widening, and constitutes a serious challenge to the government. In comparison, indigenous populations in other countries with a colonial history such as the Maoris in New Zealand and Indians in North America have life expectations that are much closer to those of the corresponding total populations. Major causes of this excess mortality are circulatory diseases, diabetes, cancer, renal failure, respiratory conditions, injury and poisoning. But diseases more typical of underdeveloped countries, such as rheumatic fever, trachoma and endemic skin conditions, are also common in the indigenous peoples. The reasons for these poor outcomes are easy to guess, including poverty, unemployment, poor education, poor nutrition, poor housing and poor hygiene.
Pharmacy and pharmacists
There are about 5,000 community pharmacies in Australia (one for every 3,800 people compared with one per 4,500 people in the UK). Pharmacy ownership is largely restricted to registered pharmacists, and in most states, one pharmacist can own, at the most, three pharmacies. Around 96 per cent of community pharmacies are therefore independents. The main exception to this is pharmacies operated by friendly societies, most of which were established in the early 20th century before legislation restricting pharmacy ownership to registered pharmacists was introduced. Pharmacy chains and “supermarket pharmacy” do not really exist, although this situation has been challenged by the government. Department stores and companies, such as Woolworths, are interested in owning pharmacies, although in the first instance, independent pharmacists will be invited to rent out space, rather than the companies opening pharmacies themselves.
Of the 14,000 working pharmacists in Australia, just over 11,000 (80 per cent) are community pharmacists. All pharmacists are required to undertake four years of university education and then one year of practical preregistration training.
Prescription medicines are paid for partly by the Pharmaceutical Benefits Scheme (PBS) and partly by patient co-payments. Under the PBS, which is administered by the Health Insurance Commission (HIC), approximately 2,500 brands of prescription medicines are subsidised by the government. On dispensing one of these medicines, the pharmacist is paid the manufacturer’s price (as negotiated by the government and supplier, and including a 10 per cent margin for the wholesaler), plus a mark-up of 10 per cent (which is reduced when the cost of the medicine reaches A$180). In addition, there is a currently a dispensing fee of A$4.50, which is generous, although Australian pharmacists grumble, as we do, that dispensing margins are falling.
The patient co-payment varies between A$3.50 per prescription for older people and others eligible for concessionary rates and A$23.10 for most other patients. However, once a monetary threshold is reached in a calendar year, PBS medicines are free for pensioners and non-concessionary patients pay A$3.70 per item for the rest of the year. Patient eligibility must be checked by the pharmacist and the Medicare number or other relevant entitlement number marked on the prescription. Unless this is done, the pharmacist will not be paid.
Truly generic medicines are not as common as they are in the UK. Instead, “branded generics” tend to be used. If a doctor prescribes a relatively expensive brand and the patient wants that particular brand, he or she must pay the difference between the expensive brand and the lower priced brand. In Australia, pharmacists can substitute expensive brands with a less costly brands.
Medicines are categorised in a similar way to ours: prescription-only medicines (POM) and over-the-counter (OTC) medicines. However OTC medicine categories are slightly different in that there are three categories. First, pharmacist-only medicines (eg, steroid nasal sprays, hydrocortisone cream 1 per cent), which must be sold in a pharmacy under the supervision of a pharmacist and are not available for self-selection. Secondly, pharmacy-only medicines (eg, ibuprofen, larger packs of paracetamol, some cough and cold preparations), which can be sold only in a pharmacy but need not be placed behind the counter. And, thirdly, general sale list medicines, which can be sold in other outlets.
POM to P shifts are occurring but not as fast as in the UK. There is also a plan to shift smaller packs of ibuprofen from P to GSL, surrounded, as you might imagine, by all the debate we had in the UK over the same issue a few years ago. All OTC medicines can be advertised directly to the public, although the number of pharmacist-only medicines that can be advertised is limited. Prescription medicines may be advertised only to health professionals.
Community pharmacists provide a range of additional services, all of which will be familiar to pharmacists in the UK. These include blood pressure measurement, cholesterol screening, advice on common ailments, participation in community health programmes, distribution of health education material and so on.
Australian pharmacists are being paid to conduct medication reviews in patients’ homes and in residential homes. In the case of the former, the pharmacist must visit the patient at home. The review is not conducted in the pharmacy and payment is A$140 (approximately £56) per patient. The GP also receives A$120 for participating in the scheme. Pharmacists are trained and accredited to conduct reviews and 80 per cent of community pharmacies are registered to provide this service.
Medication reviews are provided to residents in homes and the current remuneration is A$100 per patient per year. The pharmacist who provides this service can be the owner, an assistant pharmacist who works in the pharmacy or a pharmacist employed especially to conduct the review. However, the Pharmacy Guild of Australia (an organisation with a similar role to the National Pharmaceutical Association) wants to change the current model to provide an additional payment to pharmacies that both supply the medicine and conduct the medication review. This aims to ensure that the pharmacist performing the review is linked to the pharmacy supplying the medication, which should not only encourage drug use evaluation (DUE) by the pharmacist but also provides the opportunity for the pharmacist to train care staff on medication issues.
A national network of 96 facilitators supports and facilitates the pharmacists on an ongoing basis and encourages a collaborative relationship between pharmacists and GPs.
In rural areas, a network of health organisations controlled by indigenous communities seek to deliver culturally sensitive health care. This includes the Royal Flying Doctor Service (RFDS), which through 12 base stations, provides a range of medical services, including routine clinics at communities that are unable to attract full-time medical staff. The RFDS also supervises numerous small hospitals that normally operate without a doctor. Such hospitals are staffed by nurses who communicate by telephone or radio with their RFDS doctor. The 1,250 community pharmacies in rural areas are also a vital health care resource.
Although more money is spent on health care for indigenous people than on Australians in general, spending falls far short of what is needed on equity grounds. This situation is becoming increasingly obvious in the light of recent reports on poor health outcomes in indigenous people. Poor access to health services is cited as being one of the major causes of this inequality. For example, there is a serious maldistribution of pharmacists across rural Australia. A number of initiatives have been developed to address this issue, including a start-up allowance of A$100,000 to open a pharmacy in a remote area and an allowance of A$60,000 to buy a pharmacy at risk of closure. There is also an emergency locum service which provides a replacement pharmacist within 24 hours in situations where a sole pharmacist is forced to close the pharmacy during periods of illness or bereavement. Financial support also exists for attending training events, and there is a scheme to support indigenous youngsters from rural areas wishing to become pharmacists. Pharmacy students are encouraged to acquire the skills to practice in rural areas and this is facilitated by the schools of pharmacy negotiating placements in these areas.
Community pharmacists in remote areas may be involved in supplying medicines in bulk to Aboriginal medical services. In some cases these services can be thousands of miles from the nearest pharmacy and an allowance of between A$2,000 and A$4,500 per annum may be paid to the pharmacist for providing a range of services to these remote organisations.
Working as a pharmacist in Australia has strong echoes of UK practice. For the time being, reciprocal agreements exist between the UK and Australia. However, pharmacists tempted by the sunshine and the outdoor life do need to pass an examination for every state they choose to work in. And another thing you need to bear in mind: your fuel bills will probably be as high in November through to March as they are here. Why? Air conditioning guzzles electricity!
• Community pharmacy in Australia. Pharmacy Review (Official Journal of the Pharmacy Guild of Australia) September 2003;27:AE1–32.
• Buckley P, Marley J, Robinson J, Turnbull D. Country profile. Australia. Lancet 1998;351:1569 –78.