Replacing pharmacists with robots isn’t the answer to better productivity

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Pharmacists aren’t just dispensing machines.
from http://www.shutterstock.com

Helen Dickinson, UNSW

Reforming pharmacy services and the role of pharmacists is one of the recommendations made in a five-year review of the nation’s productivity, released yesterday. The Productivity Commission’s report, Shifting the Dial, highlights community-based pharmacy as a “significant unnecessary cost to the nation” and asks whether automated dispensing machines could replace pharmacists.

In recent years, community pharmacy profit margins have eroded as warehouse-style pharmacies offer lower prices and supermarkets and other retailers sell more non-scheduled medicines and complementary medicines. Some smaller pharmacy operators have questioned their viability and report feeling under threat. A number of pharmacists have already left the industry in anticipation of further pressures.


Read more: Discount chemists are cheapening the quality of pharmacy along with the price


The Shifting the Dial report argues pharmacists are constrained in offering quality health outcomes:

the availability of unproven and sometimes harmful medical products and confectionery at the front of the pharmacy is not reconcilable with an evidence-based clinical function at the back.

The Productivity Commission’s answer is automatic dispensing machines, supervised by a “suitably qualified person”. Along with the machines, pharmacists would play a “new remunerated collaborative role with other primary health professionals” where cost-effective.

These changes would mean there would be less need for the current 20,000 pharmacists around the country.

Automated dispensing

The idea of using robots to dispense drugs is not a new one, either in Australia or internationally. Automated dispensing devices have been used widely in hospitals around the world since the mid-1990s as a way of reducing medication errors, improving patient safety and decreasing costs. Over the last decade these devices have expanded into community pharmacy settings as financial pressures have driven the search for efficiencies.

Automated systems can reduce the error rate in dispensing medicines, but they also introduce different types of errors into the system too. Entering prescription details wrongly or not loading the machine correctly can have significant impacts.

Automated systems are expensive to buy so may not be cheaper over the short term, particularly when we consider the average wage for pharmacists is relatively modest. A recent government report notes:

[in] Australia, pharmacy graduates had the lowest starting salary of all industries requiring higher education training.

Given the investments required to buy automated machines it may be that not all local pharmacies have these. We may see the emergence of a hub and spoke model. This involves prescriptions coming into pharmacies, being sent electronically to a centralised dispensing hub and then returned to the pharmacy to dispense. This can be done either in person or via courier delivery.

This type of model is argued to be cheaper than the conventional system as it requires fewer pharmacists to run overall.


Read more: Robots in health care could lead to a doctorless hospital


In the UK there’s been pressure for community pharmacies to increasingly embrace automation for some time now. It’s well known their National Health Service has significant budgetary challenges and is looking for ways to save money. Plans to cut costs in pharmacy alongside commercial pressures from large chain providers, supermarkets and online prescription providers are predicted to cause the closure of up to a quarter of pharmacies.

This has, unsurprisingly, been met by significant resistance from the pharmacy profession as it challenges the existence of some jobs and will mean a move for others. But there’s good reason for others to be worried about these changes in terms of the impact on the broader health system.

Pharmacists can also offer advice on managing chronic conditions.
from http://www.shutterstock.com

The importance of pharmacists to the health system

Community pharmacists provide a number of functions that go beyond simply dispensing medications. In recent years we’ve seen pharmacists move away from just being those who fill our prescriptions, to people with a large amount of clinical knowledge who can advise how to take medicines safely and how to manage chronic conditions.

As increasing numbers of people experience chronic illness and take multiple forms of medicines, advice on how to do this in a safe and manageable way is crucial. Pharmacists are also probably one of the more accessible parts of the health system. Many of us will have sought advice from a pharmacist about how to manage an injury or illness, or what to do with a sick child if we can’t access a GP.

We’re seeing increasing calls to embed pharmacists within primary care teams to help better manage chronic disease. With growing numbers of individuals living with chronic disease and taking medication, pharmacists can play an important role in educating and advising on medication management.

This could improve medication use for consumers and reduce errors for those with chronic disease. Making greater use of pharmacists could reduce demand for GPs and other more expensive health professionals. For over a decade, pharmacists in the UK have been able to complete additional training that allows them to prescribe medication, helping to address shortfalls in the GP workforce.

Although the Productivity Commission report envisages a new role for a smaller pharmacy workforce, there’s little detail on what this might look like. And it underestimates the role pharmacists play within the broader health system.

If the changes outlined in the commission’s report are realised you might have your prescriptions dispensed by a robot in the future. But, it’s unlikely this will make a huge impact on the overall efficiency of the health system, and we would lose some of our most accessible clinical professionals in the process.

Helen Dickinson, Associate Professor, Public Service Research Group, UNSW

This article was originally published on The Conversation. Read the original article.

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How is the NDIS faring so far?

Last night I went on the ABC Radio show Nightlife to discuss how the NDIS is faring so far, a few months after the national roll out started.  The show was hosted by Philip Clark and I was joined on the panel by Fiona May, CEO of ACT Disability, Aged and Carer Advocacy Service.  We discussed why the NDIS came about, what some of the impacts have been and what needs to happen in the future.  A number of callers joined us with their perspectives for the second half of the show.

If you missed it you can catch the show here.

Emergency material and financial aid project

Over the last few months myself and colleagues at the Public Service Research Group have been working with the ACT Government around their Emergency Material and Financial Aid (EMFA) program.  The ACT Government is considering the nature and effectiveness of its EMFA program and we undertook an evidence review into EMFA programs, highlighting key tensions and issues in relation to Emergency Relief.  In this review we set out an overview of the types of services that these programs comprise, the evidence base around their effectiveness and the types of challenges and issues that EMFA services encounter.

Earlier this year we used this evidence review to facilitate a discussion with a range of stakeholders in the ACT around the degree to which local patterns in EMFA services match those in the literature and what might be done to further develop existing EMFA services.  The ACT Government is now embarking on a co-design approach that will seek to draw on key stakeholder perspectives and best practice in terms of the evidence base.

You can find the full evidence review here.

Individual funding systems: what works?

I have written much on this blog of late regarding the National Disability Insurance Scheme and the various research projects I am involved with around this.  But Australia is not the only country to have adopted an individualised funding approach and there is significant evidence from other jurisdictions about these schemes.

I have recently written an article for Evidence Base – which is the journal of the Australia and New Zealand School of Government – summarising the evidence relating to individual funding schemes.

What the review finds is some significant issues in terms of the quality of the research evidence.  However, there are a number of factors that aid the implementation of these types of schemes.

The article can be found in full here and there is a short blog summarising the findings on the ANZSOG website (link here).

 

 

 

Disability and social inclusion

This week saw the launch of the website and resource ‘19 Stories‘.   This is a product of a collaboration between the Disability Research Initiative at the University of Melbourne, and Belonging Matters,  a community based advisory and capacity building resource. With assistance from The National Alliance for Capacity Building Organisations, which include Belonging Matters (VIC), Community Resource Unit (QLD), Imagine More (ACT), Valued Lives (SA), Family Advocacy (NSW) and JFA-Purple Orange, people with disabilities were invited to submit their stories from all over Australia.  This is in response to the fact that although a number of people talk about social inclusion, it is not always clear what this actually means and what it looks like when done well.  

The 19 stories capture the diverse ways that people are living inclusion. The stories help others get to the essence of what ‘inclusion’ can mean in practice, in the lives of this who are doing it.  These are strong and positive stories about the ways in which people with disabilities are engaged within their communities.

I had the pleasure of being asked to write a reflective piece drawing together the systematic review that the research team did around disability and social inclusion and the kinds of policy mechanisms that Australia has developed to date with the 19 Stories hosted on the website.  In this I reflect on the tendency of many of these policy to seek to ‘fix’ people with disabilities and not engage with the broader population,  I argue that until we consider social inclusion as being about everyone and not just people with disabilities, then it is unlikely we will succeed with this aim.  You can find this piece here and I highly recommend checking out the stories and resources on this website.

Life Matters

Last week I had the pleasure of going on the program Life Matters on Radio National to discuss the NDIS.  I was part of a panel brought together to discuss the roll out of the NDIS, some of the successes to date and some of the challenges now and in the future.  I was joined on the panel by two wonderful people – Leah van Poppel of the Youth Affairs Council of Victoria and Kevin Stone of the Victorian Advocacy League for Individuals with Disability.

We had a great discussion of the NDIS and its impacts on disabled people that involved research, advocacy and consumer perspectives.  You can catch the version of the discussion here.

 

 

Launch of the Centre of Research Excellence in Disability and Health

I have written before about the fact that I have the great pleasure to be involved in an NHMRC-fundedCentre of Research Excellence in Disability and Health (CRE-DH).  This is the first of its kind internationally and is Australia’s new national research centre to improve the health of people with disabilities.

Last week we had our public launch with a debate titled ‘what makes us healthy’.  The event was hosted by Julie McCrossin, and guest speakers included the Disability Discrimination Commissioner Alastair McEwin, performer Emily Dash, and journalist and appearance activist Carly Findlay, speaking about their personal experiences of health and happiness.  It was a great launch and if you missed it there is a great write up of the event and the centre’s approach on the Power to Persuade site written by Celia Green and Zoe Aitken and you can find this here.  Croakey also republished this piece with pictures of the event and some tweets from the audience here.

Co-lead for the CRE-DH, Professor Anne Kavanagh was busy in the run up to the event writing pieces for the Australian on Pauline Hanson’s suggestion that children with disabilities should be excluded from mainstream schools, link for this is here.  Anne also did a piece for Pursuit on the new CRE-DH, which can be found here.

If you are looking for a research role there is a postdoctoral fellow in health inequities being advertised by the University of Sydney and you can find the advert here.  Stay tuned for more updates about this exciting initiative.

Victorian Parliamentary library video

We have been doing a lot of promotion of the research we did funded by the Melbourne Social Equity Institute into the National Disability Insurance Scheme of late.  One of the things we had the chance to do was to present at the Victorian Parliamentary Library. Myself and two of the community researchers presented the findings and took questions from an audience including a number of MPs from the Victorian government.  Other community researchers joined us in the audience and took part in the discussion that followed.

In addition to having a wonderfully beautiful library, the librarians are very adept with knowledge translation via social media and have produced a short video clip on our research.  You can find this here (if you can bear to look at my face for a few minutes).

The NDIS costs are on track, but that doesn’t mean all participants are getting the support they need

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Many people who are dissatisfied with the scheme have reported they couldn’t find care providers to deliver their funded and approved plans.
from shutterstock.com

Helen Dickinson, UNSW

The National Disability Insurance Scheme (NDIS) is “on track in terms of costs”, according to a position paper released by the Productivity Commission this week. The report further stated that:

if implemented well, it will substantially improve the well-being of people with disability and Australians more generally.

But the Commission’s paper also expressed some significant concerns at the speed the scheme is being rolled out, and that this could undermine its overall effectiveness. The report highlighted a number of areas that are proving challenging for those accessing the scheme. It noted that such barriers to access are, in fact, contributing to keeping the costs on track.

Where the NDIS is succeeding

Rarely a day has gone by in recent months without a news story about the perceived failings of the NDIS. The scheme has been reported as “plagued with problems” and concerns aired about a potential “cost blowout” .

As a result, the government asked the Productivity Commission to undertake an independent review into the overall costs of the scheme, its value for money and long-term sustainability. The full report is due by September.

The current position paper goes to great lengths to acknowledge the size of the challenge in delivering the NDIS. It argues that the

scale, pace and nature of the changes it is driving are unprecedented in Australia.

When fully implemented, the scheme will involve the delivery of individualised support to 475,000 people at a cost of A$22 billion per year.

There is no doubt the NDIS is complex, but the Commission finds that there is “extraordinary” commitment to the success and sustainability of the scheme. It notes that making the scheme work is not simply the job of the National Disability Insurance Agency (NDIA), but also that of government, participants, families and carers, providers and the community.

Based on the data collected, the Commission finds NDIS costs are broadly on track with the modelling of the NDIA. A greater number of children are entering the scheme than expected, leading to some cost pressures, but the report notes the NDIA is putting initiatives in place to help deal with these challenges.

The report also finds benefits of the NDIS becoming apparent, with many, but not all, NDIS participants receiving more disability support than previously and having more choice and control.

Problems with the scheme

Many people who are dissatisfied with the scheme have reported they couldn’t find care providers to deliver their funded and approved plans. This kind of under-utilisation of services is a factor contributing to keeping costs on track. Such findings are in line with recent independent research into consumer experiences of the scheme.

Overall the report finds there is insufficient flexibility in the NDIA’s operational budget and that money could be spent more in a way that reflects the insurance principles of the scheme, such as greater amounts of funding being invested in prevention and early intervention services.

The process of care planning needs greater attention. Pressure on the NDIA to get numbers of people on to the scheme means that the quality of the care planning processes have been decreased in some cases. This has caused “confusion for many participants about planning processes” and has resulted in poor outcomes for them.

There is a significant challenge in relation to the disability care workforce. The Commission estimates that one in five new jobs created in Australia in the next few years will need to be in the disability care sector. The report notes that current approaches to generating greater numbers of workers and providers are insufficient.

A range of responses required to address these include a more targeted approach to skilled migration, better market management, and allowing formal and informal carers to provide paid care and better price monitoring and regulation.

The interface between the NDIS and other disability and mainstream services has also proved problematic. There is a lack of clarity in terms of where the responsibilities of different levels of government lie and who should be providing which services. Some people with a disability have lost access to supports they used to get as state government disability services close down.

Need for political will

The Commission describes the roll-out to the full scheme as “highly ambitious” and expresses concern it risks not being implemented as intended. Indeed the speed of the NDIS roll-out is described as having “put the scheme’s success and financial sustainability at risk”.

The report concludes that if the scheme is to achieve its objectives there needs to be a

better balance between participant intake, the quality of plans, participant outcomes, and financial sustainability.

The NDIS is taking a number of steps to deal with these issues but the Commission “is unable to form a judgement on whether such a refocus can be achieved while also meeting the roll-out timetable”.

The ConversationWhat all of this means is that we will need to see some enormous political will to enable the scheme to be supported to reach its full potential. This will likely involve some slowing of the timetable for implementation and some difficult work to deal with a number of the areas that have been identified as problematic. Whether the government has an appetite to see this through remains to be seen.

Helen Dickinson, Associate Professor, Public Service Research Group, UNSW

This article was originally published on The Conversation. Read the original article.