Pharmacists have always been well regarded by their patients for their ability to deliver health literacy programs, over the counter in semi-private spaces in roughly three to five minute segments.
Generally, this service has been delivered free of charge and it has formed a nearly invisible component of “core” business.
Only invisible because it was free, and there were never any metrics applied to measure the service, its quality and its cost and what were the outcomes.
Quantified, the outcomes would have even astounded the pharmacist practitioners.
But it has always been highly valued by patients and they have always looked for increased access to pharmacists for that reason.
On the other side, pharmacists found themselves bogged down in an increasingly regulated PBS dispensing system with rigid processes that had to be followed.
Little innovation occurring under the weight of the system except in the creative adaptation to shoehorn the system into your community pharmacy environment with the minimum of friction.

Mostly, pharmacists managed this process, but the time component available as a balance between PBS operations and patient expectations meant that pharmacists had to always default to the pressure of the PBS delivery process.
Patients almost became an interruption to the day, especially if they requested pharmacist time at the moment the unfinished prescription pile was increasing in height quite rapidly.
Pharmacist body language gave them away at the point of patient engagement because of the constant concern of the pharmacist looking over their shoulder at the pile of mounting prescriptions.
Patient disappointment occurred at that point as they realised they did not have the full attention of the pharmacist and that they may have had an incomplete solution to their problem.

Thus, patient drift to other health care modalities began and natural therapists became the beneficiaries.
GP’s certainly did not fill any gaps as their role has evolved to a highly priced gatekeeper activity, wearing out patient shoe-leather by referring them to endless specialists for actual treatment.

With the decline in pharmacist time involved in health literacy activities, research has uncovered metrics involving the identification of low levels of health literacy in lower socioeconomic areas.
Concurrently, the populations living within these areas exhibit higher levels of illness, particularly chronic illness.
It is thought that this is occurring through cost pressures creating poor dietary (and cheaper) choices, and reduced access to health professionals, again reflecting costs.
i2P research indicates there may be a correlation between reduced pharmacist professional time resulting in less unpaid health literacy activity, which is resulting in a massive increase in public health costs.
Therefore, there is a good argument for government to invest in pharmacist-delivered health literacy consultations and programs – because they are the best professional resource with a proven track record.
And health literacy must be the key to delivering any Self Care program model – also identified as being best delivered from a community pharmacy environment.

Health literacy deficiency has now been discovered by the Australian Commission on Safety and Quality in Health Care, but they are yet to discover the pharmacy link.
Why are we so invisible?
Here’s what the Commission has to say:

“Why is health literacy important?
About 60 per cent of Australians have low individual health literacy.
Health literacy is important because if people cannot find, understand and use health-related information and services, it is hard for them to make well-informed decisions about their health and act on those decisions.
It is hard for them to know which foods to eat, how much they should exercise, which preventive health services they need, how to follow medication instructions, when to contact a doctor, how to decide between treatment options and how to maintain a care plan.
This affects their overall health and care.
People with low health literacy are more likely to be hospitalised, to need to go to an emergency department and to have poorer health outcomes.
People with low health literacy are less likely to undertake preventive health activities like mammography and the influenza vaccination, and are less likely to adhere to medication regimens.
They are also less likely to have good knowledge of their own diseases or health conditions.
Older people with low health literacy are likely to have poorer health and a higher risk of premature death.
Ultimately, low health literacy affects the safety and quality of health care.”

If you carefully note the above comments about how and why health literacy impacts health, you will notice that almost every statement parallels the activity taking place professionally within each and every community pharmacy.
The pharmacies that have focused on improved patient-centredness and appropriate patient engagement will not only have improved their professional revenue streams, but they will have positively impacted on public health in their communities as a result.
The Australian Commission on Quality and Safety in Health Care gives practical pointers in how you can promote health literacy (the information is for all health professionals).
Note the uncanny resemblance to a pharmacist daily activity with their patients.
The Commission notes:

“How can I influence health literacy?

Clinicians have to play a pivotal role in helping people understand their health and health care.
As a clinician, you are one of your patient’s main sources of information about health care.
You provide written and verbal advice about many aspects of health including:
• Preventive health
• Investigations and diagnostic procedures
• Treatment and medical procedures
• Medications and medication management
• Referrals and care pathways
• Navigating through the health system
• Expected costs and processes
• Forms including consent

Some of these things may be quite straightforward and easy-to-understand, some may be more complex and others may seem simple to some people but confusing to others.
There can be considerable variation in the skills and abilities amongst those with low individual health literacy.
For example, one person might find it easy to follow a complex medication regimen, but difficult to arrange home care for an aged parent, while another person might find the opposite.
 In addition, an individual’s health literacy also fluctuates over time.
People may find it easier to understand and act on advice when well, but harder during a time of stress or illness.

Universal precautions approach
The problem is you cannot tell which people have low health literacy just by looking at them, and you cannot tell what one person will understand or not understand. You should assume that your patients may not understand the information you provide and the advice you give about navigating their way through the health system.
This is the universal precautions approach to health literacy.

i2P has always advocated an evolutionary process into cognitive services so the approach to developing a suite of cognitive clinical services can be defined, given tangibility and only then, be marketed for a fee.
The price point should also be at consumer expectation, and if appropriate, be submitted for government subsidisation so that more value can be delivered for patients.

The evolutionary program may look like (all based on health literacy delivery):

* A three minute free consultation delivered in a reasonably private space but not necessarily in a formal clinical space (such as an office environment with support materials and staff).
This is the traditional OTC counselling service that should still be promoted and tangibly designed to differentiate it as a segment of a larger offering.

* A small group seminar where patients with issues in common can receive information from health professionals in a room suitable for delivering presentations internally or externally.
Cost per patient to be around $20 with a maximum of 12 patients delivered over two to four hours.
The purpose of this format is to properly deliver quality health literacy plus recruit patients for the next level of consultation.
This should be separately promoted using marketing systems and techniques and positioned as a segment within a total suite of services, differentiated by environment and presentation.
This format is an excellent opportunity to present new models of Self Care, particularly in a “food as medicine” concept that can be promoted as “Condition Support” and tied in with new types of organic foods appropriately retailed.

* In house pharmacy consultation in a properly fitted office clinical space, completely private and supported with resources, including equipment, systems and staff.
Formal consultations should engage patients in a properly prepared sequential process backed by adequate research on the patient’s problem.
These consultations should be of minimum duration of 15 minutes with fees charged at $30.00 to $50.00.
Patients arriving at this type of consultation should arrive through recruitment from seminars, from in-house pharmacy recruitment, from referral s from other health practitioners, or simply from walk-in patients responding to advertising or as referrals by friends.

To ensure permanence, pharmacy owners should establish a system of Continuous Cultural Change which establishes the intellectual and ethical architecture to allow changes to flow with the support of all pharmacy staff – both pharmacist and non-pharmacist.
Establishing such a system will eventually embrace research projects that will enhance and value-add to the services that evolve naturally to fill unmet patient need.
Starting with Health Literacy Programs you can be assured that not only is the program meeting an unmet patient need, but it will impact directly on public health costs.
This type of program also forms an argument for pharmacy location rules.
Access to any program is the key to its success.
Pharmacists are not only the best health professionals to provide health literacy services, but they are currently organised by location rules for best patient access.
Because this tends to ration pharmacy numbers the PGA should encourage its members to build larger practices and create new formats for new members e.g. clinical services contractor businesses.
The current PGA policy of viewing independent contractors as a leakage of business is wrong and represents a loss of opportunity.
They should embrace the exact opposite and advocate for service contractors as being an integrated expansion of core business.
Existing pharmacies promote structured management time dedicated to retailing and dispensing.
Contracted professionals promote unstructured time in delivering new services.
They need to be integrated under the same umbrella for political advocacy which would provide appropriate career pathways for new pharmacists and reduce tension between all pharmacists.
Collaboration needs to begin at home before going externally.

And pharmacists should also note that the King Review has no reference to health literacy and the major participation by pharmacists already and how they would impact beneficially on public health outcomes and costs.

The medical fraternity do seem to have an awareness of pharmacy being able to perform at a very high level.
This is perhaps the major reason for their disruptive behaviour.
They are also badly in need of a culture update because they too have been affected by the PBS having reached its life-cycle endpoint.
But their solution in disrupting all other health modalities and trying to assert control over primary health care without the leadership abilities to deliver needs to be minutely examined by their leaders and creatively and innovatively adjusted.
Then they should ask for forgiveness from the entire health care family – because they have lost total respect.

For those readers interested in accessing the Commission’s brochure on health literacy, please access here:
Health-literacy-a-summary-for-clinicians

 To access the site for the Australian Commission for Quality and Safety in healthcare click on this link.