Health Literacy – A Concept for a Valid Direction for Community Pharmacy

Recently, I had a conversation with a health professional involved in the public health system.
Research had emerged that large pockets of populations were experiencing epidemic levels of chronic illness such as obesity, diabetes, asthma, and heart disease.
These population pockets correlated with areas of low socio-economic households where people had generally poor diets and poor drug compliance, with compliance issues closely linked to insufficient funds to purchase prescription or other forms of medication.
Is there any solution?

This particular health professional felt that the health literacy levels of these population groups were very low and that improvements through government investing in programs that could lift levels of health literacy, would eventually provide better outcomes through solutions patients themselves would take responsibility for individually, simply because they have the knowledge.

I cautiously asked as to what health professions might be involved in the planning and dissemination of this type of education and found that only the “experts” were currently involved and that knowledge was being generated and shared through conferences and workshops to flesh out the priorities.
Without asking the actual question “Will community pharmacy be involved?”
I was quickly able to determine that pharmacists had not been included in any deliberations to date – nor would it be likely to happen in the near future.

Digest the following random thoughts.

Pharmacists are engaged every day in educating patients.
They have always scored higher than other health professions (including GP’s) in outcomes involving patient compliance issues.

The PBS system actually demands such education and it has a miniscule budgetary component that hides in plain sight to pay for this activity, and pharmacists do attempt to provide this service.
The payment is a farce – just a tick box some politician can point to and beat pharmacists over the head with, because it could never work.
And it has to be balanced against other overwhelming bureaucratic processes involved with the PBS product, now considered to be at the end of its life cycle with nowhere to go, and high drug prices consuming every available dollar.

With health literacy now acknowledged by public health leaders to be the key to better population health, with the potential to delay or prevent chronic illness, this now represents an unmet public health need that would have a direct positive effect on government expenditure in health budgets.

Consider the following points:

* Community pharmacies have a range of “touch points” through individual family members visiting a pharmacy for their own personal requirements.
Even if a chronically ill family member is not a pharmacy patient or even a pharmacy customer, one other family member may visit a pharmacy environment.

If that family member could influence other family members to consider an education offer, the 5000+ pharmacies around Australia could quickly deploy any patient education initiative.

* Community pharmacies are already distributed in a systematic manner throughout Australia because of PBS Location Rules.
Thus the national infrastructure for the delivery of Health Literacy is already in place and cost to government would be minimal if this unmet need could be negotiated as a public/private partnership that would have a greater health impact than the monoculture of PBS dispensing.
It follows that there would be a definite public benefit in retaining location rules and that pharmacy leaders should be pursuing additional public/private partnerships to offset PBS losses immediately, or even in the future should PBS be lost to other locations such as public hospitals.

* PBS dispensing does have a miniscule budgetary component for patient counselling of the drug prescribed and dispensed.
This is not the holistic process a patient needs, and in turn, the patient will not always understand the need for compliance without a further elaboration.
A Lifestyle Plan needs to be more of the approach to be taken where the patient can see where they fit into a program in which they “star” – right at the centre!
This could be a major format for pharmacist patient engagement and a system where collaboration with other health professions could link in, for that patient.
A pharmacist referral system should also be a component of this system as well as a limited prescribing function that can link back to and enhance the moribund PBS product.
The prescribing process can be integrated as part of a doctor initiated process where a protocol is established for a pharmacist to work with.
This component is not a new idea but it is long past the time it should be implemented.
If the whole concept of Health Literacy systems was to be developed from the almost invisible drug counselling component of the PBS then it can be funded from budgets that already exist at both state and federal levels for such literacy programs.
Its effect would be to improve patient health, reduce national health budgets and if the additions of referral and protocol prescribing were accepted, it would extend the life cycle for the PBS, while simultaneously allowing for a small reduction in PBS costs, as pharmacists access other health education budgets for their Literacy Health program cost reimbursement.

* The King Review has been basically established to decide what should happen to the PBS, now at the end of its product life cycle, and also decide what to do with the pharmacists now disoriented because of PBS disruption, and potentially displaced as non-pharmacist ownership becomes part of the discussion under Ownership Rules.
What I have described above provides a more attractive deployment for pharmacists because it creates an evolutionary process (rather than a revolutionary new process) that allows pharmacists to innovate their own ideas to fit in with Health Literacy official policies to fill an unmet public need.
Pharmacists have always been patient educators, even though PBS procedures have caused a diminishment of this activity.
Government and the Australian public would become the “big winners” from the enhancement of what has always been done, into a recognisable and universal system format.
A “win-win” situation also as pharmacists would not have to rely on a commoditised PBS process from which to earn a decent income.
Is there any pharmacy leader that would be willing to take such a proposal to the King Review and beyond?

* Internally, the two major leadership organisations – PSA and PGA – would be able to form a partnership built around different elements of Health Literacy.
PSA could develop the intellectual content and basic research for the project while PGA could polish up the infrastructure components through its member pharmacies and create “outreach” forms of marketing to recruit patients.
Franchised market groups would have to adapt to new opportunities.

* Individual pharmacies would need to identify and register their patients while still retaining a customer flow from retailing.
Internal marketing systems will have to be designed to convert customers (the original “touch point” referred to at the beginning of this points list) to registered patients.
Registered patients can then be organised into different group levels of education systems, depending on their Health Literacy needs, which are assessed by experienced pharmacists.
At that point pharmacist creativity and innovation takes over in internal pharmacy system design, and there is also an opportunity for research projects to be developed and attract grants to a pharmacy practice level that has not traditionally  involved itself in such a process.
Here also lies an opportunity for academic pharmacists and a seamless link back to university level research projects.

* A diversion of pharmacist focus to Health Literacy will create opportunities for pharmacists at all stages of their career, including senior and semi-retired pharmacists (they have lifelong experience in patient engagement) and younger pharmacists, as they develop internal programs that may fill identified needs that flows out of Health Literacy experiences.
Proper remuneration needs to be negotiated to encourage participants and clinical pharmacist incorporated practices should be encouraged to invest in their pharmacy practice and create the arms-length necessary to expand into prescribing activities.
Protocol prescribing would eliminate conflict of interest issues that would arise if pecuniary interest was involved in the actual pharmacy.
Independent prescribing would be more politically accepted by independent clinical pharmacists that do not have pecuniary interest in the pharmacies they contract to.

Health Literacy holds out the potential for pharmacies and pharmacists to develop a range of gatekeeper roles in public health that can, in turn, stimulate all pharmacy practice and create stability through not being reliant totally on PBS as an income source.
Retail expansion would similarly not require the amount of resource needed (human, financial and space) to sustain that activity, traditionally developed to plug income gaps that have occurred in professional revenue streams (such as PBS).
All that would be required is a logistics system that caters for dispensing and a tailored front-of-shop inventory to attract sufficient customers for conversion to an increasing registered patients stream.

It is my hope that the information and ideas contained in this article can act as a catalyst to unite all levels of pharmacists to a common cause, that can also lead to a diversity in pharmacy practice that can co-exist, collaborate and enhance the “community pharmacy brand”.
I think we all know that if something realistic is not formulated as a universal direction, we will have something imposed on us that will never be a “fit”.
And that will cause us collectively to haemorrhage further,  particularly as we are beginning to lose our “best and brightest” through not being able to pay them appropriately, and to not provide harmonious workplaces that encourage job satisfaction through innovation to fulfill career aspirations for all levels of pharmacists.

Pharmacy owners have always been required to produce an adequate return on investment sufficient to sustain a pharmacy practice with minimum pressure.
That has not always been possible in recent times and some have disappeared permanently.
The solution is to change direction and be courageous enough to invest in change and to build trust at all levels.
That is the “glue” that binds – sufficient for our general public to keep us affectionately as part of their life health plan.
And that will make us impervious to any attacks from external sources.


For further reading please access a paper prepared by The Australian Commission on Safety and Quality in Health Care at:

2 responses to “Health Literacy – A Concept for a Valid Direction for Community Pharmacy”

  1. Thank you for an interesting and thought-provoking article.
    When I worked for PSA in the pharmacy practice improvement program, offering health education was one of the ways I advocated to build community health literacy. Unfortunately, it is a time-consuming and costly activity for pharmacists to become involved in, and there are few ways of measuring the returns on time spent in outreach…especially when potential customers can take the advice to the nearest Chemist Warehouse for the cheapest solution.
    We need to build a business case based on pharmacoeconomics to show the benefits to the whole community (from funders through to patients, via decreased hospital admissions or GP visits) showing that increased usage of pharmacists can keep patients out of hospital, can keep them healthy and can do it at much lower cost (and without a wait time) than the current system that is locked almost entirely to medical practitioners (either in community or in the hospital) prescribing large quantities of drugs without the ability to monitor and/or aid compliance or decide whether the offered solution is culturally appropriate or acceptable to patients.
    Here are the stats confirming that 65% of the Australian population aged over 45 have 2 or more co-morbidities: see box ‘Comorbidity of selected chronic diseases, by age, 2014–15’
    As to pharmacist participation in policy making and evaluation may be pharmacists are not widely enough educated for that role – PwC did not have a single pharmacist in their Sydney-based national health team until about 7-8 years ago…

  2. Hi Jane, and thank you for your comments.
    Some of the writers at i2P have had management consulting training and experience over a long period of time.
    I mention this because the culture of management consulting is based in problem-solving and finding practical solutions.
    Management consultants are also notorious for not disclosing their own research, because unique knowledge is the intellectual asset that underwrites fee generation.
    Nothing dissipates faster or travels more quickly than good but free information.
    Aspects of a Health Literacy service have already been tested within a restricted network of i2P pharmacists and associates.
    A larger pilot study is planned for later this year.
    All elements of the system to deliver Health Literacy are planned to be self-funding through revenue generation and not be dependent on government funding.
    That is not to say government grants or seed funding would not be welcomed because it would speed up the entire process.
    Integration of a Health Literacy program with other existing health systems is also planned, particularly self-care and elements of primary health care services.
    A series of pilots involving interested pharmacies could provide the data for a business case for recurrent government funding.
    Given your personal interest and experience with PSA and Health Literacy programs I am sure that i2P associates would be willing to share knowledge with you under a confidentiality agreement.
    Peter Sayers

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