PN1547

VICE PRESIDENT HATCHER: Mr Irving?

MR IRVING: Thank you. Two final witnesses from the Association. The first is Professor Krass, and before I do so perhaps I will just tender these documents now. The first is the second CPA and then the third CPA and then the sixth CPA. There are three additional CPAs and if I had access to a photocopier and the printing processes I would be able to print them off, but I have been somewhat limited in that. We have no objection if the other CPAs are added to the evidence later by the respondent.

EXHIBIT #13 BUNDLE OF COMMUNITY PHARMACY AGREEMENTS

PN1549

Thank you. I now call Professor Krass.

<INES KRASS, AFFIRMED�� [10.06 AM]

EXAMINATION-IN-CHIEF BY MR IRVING�� [10.06 AM]

PN1550

Professor Krass, are you a professor of pharmacy at the University of Sydney?‑‑‑I am.

PN1551

Have you been a lecturer holding various academic positions at the university for the last � since about 1993?‑‑‑That's correct.

PN1552

Have you published over 126 referee publications?‑‑‑I can correct you there actually, it's 200, but - - -

PN1553

Is your research focused on health services researching community pharmacy?‑‑‑It is.

PN1554

Have you prepared with others a report for the purpose of these proceedings?‑‑‑Yes, I have.

PN1555

Could I take you to the folder you have in front of you, tab number 4, is that a report titled "Work value of community pharmacist"?‑‑‑It is.

PN1556

Prepared with Professor Aslani?‑‑‑Yes.

***�� INES KRASS�� XN MR IRVING

PN1557

If I can take you behind tab 4.3 is that a report titled "Work value of community pharmacist part 2 semi-structured interviews"?‑‑‑Correct.

PN1558

Was that report created under your supervision, or that study done under your supervision?‑‑‑Yes.

PN1559

I tender those two reports, your Honour.

EXHIBIT #14 REPORT ENTITLED "WORK VALUE OF THE COMMUNITY PHARMACIST" PREPARED BY PROFESSOR PARISA ASLANI AND PROFESSOR INNES KRASS

EXHIBIT #15 FURTHER REPORT "WORK VALUE OF A COMMUNITY PHARMACIST PART 2 SEMI-STRUCTURED INTERVIEWS" PREPARED BY DR VIVIAN TONG, PROFESSOR ASLANI AND PROFESSOR KRASS

PN1560

If I could also tender the CV of the professor, which is contained in the materials which were initially submitted by the Association on pages 41 through to � there's so many articles � 41 and following.

EXHIBIT #16 CURRICULUM VITAE OF PROFESSOR INNES KRASS

PN1561

I have no further questions of the witness.

PN1562

VICE PRESIDENT HATCHER: Mr Seck.

CROSS-EXAMINATION BY MR SECK�� [10.09 AM]

PN1563

MR SECK: Thank you, your Honour. Professor Krass, there are two reports which have been tendered; exhibit 14 which is the joint report with Professor Aslani, and exhibit 15 which is the report, part 2 of the report, with Professor Aslani and Dr Tong. Do I take it that the reports are joint reports?‑‑‑Correct.

PN1564

So your involvement in preparing both reports was I think as the most senior person supervising the project, reviewing it and settling it?‑‑‑I supervised it � well, it was equally supervised by myself and Professor Aslani, so we were co-investigators if you will, and in fact she had � she had the key role and � but I was involved throughout the process in developing the methodology, reviewing the results, interpreting the results and finally preparing the reports.

***�� INES KRASS�� XXN MR SECK

PN1565

Do you recall at the start of the process you received a letter of engagement which was entitled "Commission of research brief" setting out what you were asked to undertake as part of preparing the report?‑‑‑Yes.

PN1566

Do you have a copy of that with you?‑‑‑No, I don't. As I said Parisa Aslani was I guess � she took � you know, took control of that, you know, the procedural matters. I don't have a copy of it, no.

PN1567

I don't know if it's made its way into the folders, but just so the Bench can follow it's annexure E to the submissions and outline of findings to apply to APESMA on 5 April 2017, and I would provide a copy to you, Professor Ines, but I don't know if copies are contained in that folder and I don't have a spare copy. So I apologise if I'm going to read from the document.

PN1568

VICE PRESIDENT HATCHER: These are the findings to be made on expert evidence?

PN1569

MR SECK: That's so, and it's annexure E starting at page 93 and if the Bench wishes to follow. I think we might be able to provide a copy to you. I don't mind if it's highlighted. I am grateful to my learned friend for supplying his copy. Professor Krass, I have just provided you what is annexure E to the submissions and lay evidence, "Outline of findings with APESMA", which APESMA submission should be made on the expert evidence dated 5 April 2017. Is that a document you recognise?‑‑‑I recognise components of it. I certainly recognise the section that is highlighted here, "What is required", because I helped � I helped in designing that.

PN1570

When you say you recognise it do you recognise it in this particular document or - - -?‑‑‑No, no, I recognise the wording.

PN1571

All right, you recognise the wording but you don't recall this specific document itself?‑‑‑No, because I was not involved in this � in this transaction if you will.

PN1572

You see just in the research proposal on page � and I'm using the page numbers in the bottom right-hand corner � page 93 of 239, do you have that, Professor Krass?‑‑‑Yes, I have.

PN1573

It's to investigate changes in work value of a community pharmacist comparing 1998 with 2016. You understand that was the purpose of your reports?‑‑‑Yes.

***�� INES KRASS�� XXN MR SECK

PN1574

In a general sense?‑‑‑Yes.

PN1575

There were to be two parts to your report. If you go over to page 95 you see "What is required"?‑‑‑Mm-hm.

PN1576

And it's a literature review?‑‑‑Yes.

PN1577

Which I think forms part 1 of your report?‑‑‑That's correct.

PN1578

And it's to identify changes in work value between 1998 and 2016, and there are particular topics set out there in terms of what you are meant to do, and then the second part, the semi-structured interviews, which is part 2?‑‑‑Yes.

PN1579

So that's certainly your understanding of the scope of the reports that you were meant to prepare. Point 3 and point 4 I think are just the presentation of the report, that is a final report within an eight week period and gaining ethics approvals, and both of those things were done?‑‑‑Sure.

PN1580

Now if you go back to page 94 of 239 you will see � as I took you to beforehand you were to investigate the changes in the work value, and you will see that there's a background which is set out on page 93, and then on 94 it describes work value reasons. Do you see that?‑‑‑Mm-hm.

PN1581

Is that something you recognise in terms of a definition as part of what you were doing in your project?‑‑‑Yes.

PN1582

So you understood that what you were doing was identifying work value reasons, that is reasons justifying the amount that employees should be paid for doing a particular kind of work relating to matters set out in (a), (b) and (c)?‑‑‑I do, yes.

PN1583

So you understood that both your literature review and your semi-structured interviews were to be directed to these three issues, that is nature of the work, level of skill and responsibility involved in doing the work, and the conditions under which the work is done?‑‑‑And the changes.

PN1584

And the changes?‑‑‑That have taken place, yes.

PN1585

Changes from 1998 to 2016, and that was the focal point?‑‑‑Yes.

***�� INES KRASS�� XXN MR SECK

PN1586

So understanding that was the purpose of your project can I take you to part 1 of your report?‑‑‑The literature review are you talking about?

PN1587

The literature review. Am I correct in saying, in understanding that the literature review was to review both in general terms the academic literature as well as any industry or policy literature which might exist in relation to these subject matters?‑‑‑That's correct.

PN1588

Is that so?‑‑‑Yes, that's correct.

PN1589

And in conducting the literature review there are databases which you have access to at the university which allows you to conduct those searches?‑‑‑Sure. Yes, absolutely.

PN1590

Would that be the general methodology of conducting the literature review?‑‑‑Yes. So a comprehensive literature review like this would involve searching relevant databases. It would involve also seeking policy documents that are relevant to the topic, so-called grey literature, and that's � that's a standard approach to conducting a comprehensive literature review.

PN1591

In conducting the literature review, given that you understand you're comparing the work value which existed in 1998 of community pharmacists with the work value in 2016, do you recall the timeframe during which you conducted the literature review?‑‑‑The timeframe, it would have been � we would have searched over that period. I don't recall precisely, but we would have � it would have focused on that period, the changes that have taken place within that period.

PN1592

But in terms of the review would you have put in parameters in terms of time?‑‑‑Yes, absolutely. You search, you have to frame your search within certain timeframes.

PN1593

In this case you would have started your search from articles and papers in 1998 and searched for any literature between 1998 and 2016?‑‑‑And currently, yes.

PN1594

Is that how I understand it?‑‑‑Yes.

***�� INES KRASS�� XXN MR SECK

PN1595

The approach you take, and I am going to move back and forth throughout your paper, but if you go firstly to 114. There's what I thought was a summary of how you approach the question of work value and tell me if this is correct. You say, this is the last paragraph:

PN1596

Despite the incremental expansion of CPS funding - - -

PN1597

Just pausing there. CPS according to the key or abbreviations which you use in your report, which is contained for the benefit of the Full Bench, at the start of the report at page 101, CPS, sorry, stands for community - - -?‑‑‑No, it stands for cognitive pharmacy services.

PN1598

Can you explain to the Commission what is meant by the expression cognitive pharmaceutical services?‑‑‑Yes. So the term refers to any work that requires intellectual input that's not directly related to the dispensing of a medicine. So it's anything that does not directly involve the dispensing and supply of medicine. Other work that is undertaken or a professional service that is undertaken by pharmacists that is not directly related to that.

PN1599

So you say:

PN1600

Despite the incremental funding to cognitive pharmaceutical services funding with each CPA - - -

PN1601

Which refers to community pharmacy agreements?‑‑‑Mm-hm.

PN1602

- - - which indirectly reflects changing roles in practice within the community pharmacy setting.

PN1603

Just pausing there do I gather that the premise under which this logic follows is that you assume that because there's an increase in funding under the CPA that it also means that indirectly by inference there's a change in the role in practice within community pharmacy?‑‑‑It facilitated a change in role, yes.

PN1604

You say facilitated, but I think you use the word here "which indirectly reflects". Does that mean you have in effect drawn an inference that because there's more funding it must also follow there's a change in roles?‑‑‑Well, it does reflect that, because it � I guess it goes beyond that, but the availability of funding and the uptake of that funding directly demonstrates that pharmacists have been more engaged or more � much more active in terms of providing professional services.

***�� INES KRASS�� XXN MR SECK

PN1605

You would agree that assumes that before the funding was provided those services weren't being provided by some pharmacists?‑‑‑They weren't � they weren't being � I guess it wasn't done in a systematic way, in a documentable way. I mean what we do know � and it wasn't � in a very ad hoc fashion. I'm not saying that no elements of those were actually delivered prior to that time, but it wasn't done in a systematic way, it wasn't documented and it wasn't � because it was packaged if you will as a cognitive service under the CPA it then became much more prevalent if you will.

PN1606

I understand. So just to pick up your language, Professor Krass, you said it became much more systematic, much more documented - - -?‑‑‑Yes.

PN1607

- - - and not ad hoc. Would that be a fair assessment?‑‑‑Yes, and more � much more comprehensive, and was linked to specific skill � defined skills that are needed to be exercised, or needed to be acquired if you will in the � so if we take for example one of the cognitive services that has been funded was home medicines reviews, so there's a specific training and accreditation process that accompanies that. A pharmacist can't do that without undergoing that training and obtaining the appropriate accreditation. So the landscape changed very significantly.

PN1608

When I went through your report, Professor Krass, on this issue one thing I couldn't find, and you can tell me if it exists, is literature which dealt with what was being done in relation to the CPA funded CPS services prior to the CPA funding those services. Were there any academic studies or literature on that particular topic as to what was done prior to the CPAs?‑‑‑Well, it was scanned. There were some � there was some investigation of � I guess there was an investigation of pharmacist activities that were linked to the dispensing process. So there was � there was a study I think that was published in the � it was in the 1990s by Ben Remo-Odell which actually tried to investigate what pharmacists were doing around the prescription, what additional � but I guess the actual � again that was really just linked to the dispensing process. There was no � there was no investigation of some of these other services that have come on stream, you know, in the time since then.

PN1609

So in other words there's scant, if any, evidence on CPS services prior to the funding arrangements?‑‑‑Correct, yes.

PN1610

So it's hard to know what was being done before the CPAs - - -?‑‑‑Well, we do know because � sorry, I'm interrupting you there � we do know that there was � there were surveys done of community pharmacists. There were some observational studies, but the reality is that there were no cognitive pharmacy services being delivered prior to that time.

PN1611

When you say the reality, I am just focusing on the literature at the moment - - -?‑‑‑Yes, okay. Well, in the literature we have no evidence that there were cognitive services being provided prior to that time.

***�� INES KRASS�� XXN MR SECK

PN1612

And I will come back to - - -

PN1613

VICE PRESIDENT HATCHER: Prior to that time is 1998?‑‑‑Yes. Yes.

PN1614

MR SECK: I think we accept by that time didn't you mean by the time the CPA started funding the CPS services?‑‑‑Well, the CPS services really � the funding of CPS services in community pharmacy only really took hold with the � I guess in a really significant way in the fourth pharmacy, in the fourth community pharmacy agreement. Prior to that - - -

PN1615

VICE PRESIDENT HATCHER: Which was when - - -?‑‑‑Sorry?

PN1616

Which was when?‑‑‑The fourth community pharmacy agreement was 2005 to 2010.

PN1617

Thank you.

PN1618

MR SECK: But I think as you say there's no literature prior to that?‑‑‑No.

PN1619

Now, let's go to some of your findings. I want to go to page 118 which deals with the overall descriptions of CPS in the Australian community setting, pharmacist roles, responsibilities alongside perceived actual impact, which is 3.1. Do you have that, Professor Krass?‑‑‑Page 118?

PN1620

Yes?‑‑‑Yes.

PN1621

Here I think what you have done is sought to ascertain roles and responsibilities from literature which existed within the profession as opposed to within the academic literature. Would that be fair?‑‑‑No, I don't think that's fair, I think it's within � it's the full scope. We � we took a very comprehensive approach and we looked for any literature that reported on these services.

PN1622

I am talking about roles and responsibilities under this section as opposed to your report generally?‑‑‑Right.

PN1623

Perhaps the best way of dealing with it, Professor Krass, is if I take you to some of the footnotes which I followed through to understand the sources of - - -?‑‑‑The information?

***�� INES KRASS�� XXN MR SECK

PN1624

- - - information. You can confirm whether or not I am right or wrong in understanding the scope of the information that you relied upon in forming these or coming to these findings. One of the first things you say is in, I would say the third paragraph which is about � when I say � I am going to use point forms within the page and assume there are ten points on the page and that tells you the point at which we are looking at, but it's about nearly halfway down the page, Professor Krass, on page 118. It says:

PN1625

These standards and guidelines can in turn form the basis upon which protocols are developed and employed.

PN1626

Do you see that, Professor Krass, about half - - -?‑‑‑Yes, I do. Yes, I've got it.

PN1627

I think the standards you're referring to there are the national competency framework which you referred to earlier?‑‑‑Yes.

PN1628

And then there are other standards and guidelines which are prepared by various professional bodies; that's right?‑‑‑Yes.

PN1629

And I think what you say is that because the standards and guidelines exist they can form the basis for practices developing based on those guidelines. Am I right in understanding that's what you're saying?‑‑‑Yes, that's correct.

PN1630

To aid the pharmacist?‑‑‑Mm-hm.

PN1631

So the guidelines, the key one you refer to is the national competency standard for pharmacists in 2010, and if I go to the references, and I will move back and forth between the references and for your benefit and for the Full Bench's benefit the references, the footnotes as it were start at page 190 of the report. So the reference you have which is at footnote 3, and I think what you do you use footnotes to designate articles which are referred to in the references, it's a PSA document you will see - - -?‑‑‑Are you referring to the superscripts?

PN1632

Superscripts, yes, the footnotes?‑‑‑The references?

PN1633

The references?‑‑‑Yes,

***�� INES KRASS�� XXN MR SECK

PN1634

Pardon me, superscript reference numbers. I am going to call them footnotes, but I know they're not footnotes as it were, they're superscripts?‑‑‑No, they're superscripts. Yes, okay. So the citation, yes.

PN1635

The citation. So pardon me if I don't get the academic nomenclature right in terms of how we describe it, but the superscripts?‑‑‑Okay. That's okay.

PN1636

Page 190?‑‑‑You'll have to give me a moment. Yes, 190, yes.

PN1637

You will see it refers to � sorry, this is number 3?‑‑‑Yes.

PN1638

The Pharmaceutical Society of Australia national competency standards, framework, the pharmacist in Australia 2010 and there's a link to where it's located. So when you say these standards can in turn form the basis on which protocols are developed and employed what you're putting there is a proposition which may occur, not necessarily that there was any evidence that this was in fact occurring?‑‑‑Absolutely.

PN1639

Move forward you say in the next paragraph:

PN1640

The present CPS offered in community pharmacies in Australia - - -

PN1641

VICE PRESIDENT HATCHER: Mr Seck, I am lost, where are you now?

PN1642

MR SECK: Sorry, back on page 118, your Honour. This is the paragraph starting in the middle of the page.

PN1643

The present CPS offered in community pharmacies in Australia additional to the core dispensing related duties that are completed are described in table 3, based on those outlined by the Pharmacy Guild of Australia together with the Pharmaceutical Society of Australia.

PN1644

If we go to table 3 - - -?‑‑‑Table 3 is - - -

PN1645

Is starting at page 121?‑‑‑Yes.

PN1646

And I am not going to go through it in detail, but you see the CPS which is identified is in the left-hand column?‑‑‑Yes.

***�� INES KRASS�� XXN MR SECK

PN1647

Am I right in saying that the CPS which is identified in each of the tables are services which are funded under the community pharmacy agreements?‑‑‑Not � not exclusively. They are � in table 3 they do refer to a CPS that is currently funded. So the two that are referred to there are the home medicines review service and a residential medication management review service, and they are both funded.

PN1648

You are absolutely right. So if we go through them just so I understand which ones are funded and which aren't funded. So you describe the MMRs?‑‑‑Mm-hm.

PN1649

If you go to page 123?‑‑‑Yes.

PN1650

You have got medication management reviews, MedsChecks and diabetes, MedsChecks - - -?‑‑‑Yes. Just a moment.

PN1651

Pardon me?‑‑‑Yes.

PN1652

So you see 123 says medication management review?‑‑‑Yes.

PN1653

So that's SOAs, that's also a program funded under the community pharmacy agreements to the best of your knowledge?‑‑‑Yes, the MedsCheck and the diabetes MedsCheck are both funded.

PN1654

If you go to page 124, clinical interventions, do you see that?‑‑‑Sorry, just a sec. At 124, yes, clinical interventions, yes, they are paid for under the � under the CPS, yes.

PN1655

Then we have got medical adherence programs?‑‑‑Medication adhering programs.

PN1656

All right, so medical adherence programs, pardon me. That's not funded, is it?‑‑‑No, that's correct.

PN1657

Go to page 126, dose administration aids. Those are funded?‑‑‑Yes, they are.

PN1658

Go to page 127, staged apply?‑‑‑Yes, that's funded.

PN1659

That's funded?‑‑‑Yes.

***�� INES KRASS�� XXN MR SECK

PN1660

Continuing dispensing, known as medical continuance, that's not funded, is it?‑‑‑No, not funded. Staged supply is a � is similar, but the staged supply is the only one that's funded under the - - -

PN1661

When you say it's similar why is it similar?‑‑‑Because continued dispensing � staged supply is, I guess is about providing a small quantity and then � and reviewing the response to that and then providing � providing a further supply. Continued dispensing � sorry, it is actually � that's where � that looks at the situation where somebody has run out of a medicine. It's like an emergency supply, so if it's a schedule 4 medicine which requires a prescription, but if there's � there are certain categories of medicines that have been classified under this that the pharmacist can provide a small quantity to ensure continuity of supply without actually having the physical prescription. So it's around emergency if you will, emergency continuation so that you don't interrupt the regimen.

PN1662

I won't go through all of them because there's quite a few of them and I will come back to it shortly, Professor Krass - - -?‑‑‑Sure.

PN1663

- - - but I think we have identified the key ones which are funded under the community pharmacy agreements?‑‑‑Yes, that's correct.

PN1664

You agree?‑‑‑Yes.

PN1665

You say:

PN1666

All services must be performed to a level - - -

PN1667

This is, sorry, going back to page 118, I apologise?‑‑‑Which page are we on?

PN1668

Page 118?‑‑‑Okay.

PN1669

And I apologise that I have to take you back and forth?‑‑‑Yes, well, just give me a moment to go back. Yes.

PN1670

This is about point 6 or 7 of the page. It's the second sentence in the last paragraph:

***�� INES KRASS�� XXN MR SECK

PN1671

All services must be performed to a level which meets competency level as outlined in the national competency standard framework for pharmacists in Australia. These standards set the skill level and attributes which must be acquired by the pharmacist in order to practice as a pharmacist.

PN1672

Then you have got things about training?‑‑‑Where � sorry, which page are you referring?

PN1673

Page 118, the second sentence in the last - - -?‑‑‑Yes, okay, I've got it now.

PN1674

You have got it?‑‑‑Yes.

PN1675

So what you're saying here is that services are linked to the competency standards and you have to perform according to the competency standards. Understanding that part of what you were doing is comparing the work value in 1998 to the work value in 2016 did you as part of your findings look at what services were provided in 1998 and the competency standards which were supplied?‑‑‑Yes.

PN1676

Just so I know where did you do that?‑‑‑So what you're asking is whether or not we compared the � well, there were � there's been a process of updating of competency standards over time to reflect changes in practice, and so they actually have been updated. We � I guess we didn't look � we didn't look before � at 1998 there were no, there were no cognitive pharmacy services recognisable as such being provided, and so it's very hard to make that comparison.

PN1677

When you say there were no cognitive pharmaceutical services being provided in 1998, just assuming this is part of the literature review that you have searched for that material to see - - -?‑‑‑Yes, we did.

PN1678

On what I understand you did here is that you say competency standards relate to the services which are being provided at the time?‑‑‑Well, yes, but � that's right they would, absolutely, but the current competency standards have been, they have been updated and they have been updated commensurate with these services that have now come on stream.

PN1679

All right. I think you said beforehand there were competency standards which have developed over time; that's right?‑‑‑Yes, they've been updated on a regular basis, yes.

***�� INES KRASS�� XXN MR SECK

PN1680

To the best of your knowledge, and tell me if you know this or not, there have been competency standards that have applied in the Australian community pharmacy industry since 1994?‑‑‑Yes, there have.

PN1681

Did you do a comparison between what was contained in the 1994 competency standards and what's contained in the latest competency standards, which I think are the 2010 competency standards, to ascertain the nature and changes of the services which are being provided under the rubric of CPS?‑‑‑I don't � I don't think we reported on that. I mean I'm aware of it from my own � from my own experience as an educator because we have had to update our curricular and there have been changes. I can't tell you specifically which changes they are, but there have � I guess at various stages I've been involved in the updating of competency statements and they have been significantly changed to reflect the expanded scope if you will that's required under the provision of remunerated pharmacy services.

PN1682

I think you also used the same logic, and tell me if I am right, not only using national competency standards but also professional practice standards and other guidelines which you use, so you say if there are guidelines and standards which deal with a particular issue that as a matter of inference is likely to reflect the kind of services which are being provided at that particular time?‑‑‑It should be.

PN1683

That's correct, it should be?‑‑‑It's a standard that should be met, yes.

PN1684

Can I take you to a document � you have a number of folders in front of you, Professor Krass, and I will endeavour to find the document for you in the material. These are materials which are � pardon me if I am slow in locating the documents in the folder that you have � this is tab 24 of Dr March's reply statement, just for the benefit of the Bench, and that is contained � do you have a folder which is volume 2 of 3, Professor Krass?‑‑‑Yes, I have, yes.

PN1685

Can I ask you to go there, and can I ask you to go to 2.2.24?‑‑‑Standards for clinical pharmaceutical services?

PN1686

No, it should hopefully say - - -?‑‑‑Professional practice standards.

PN1687

Correct. That's a document I want you to look at?‑‑‑Yes, okay, it's 1999.

PN1688

You will see it's May 1999?‑‑‑Yes.

***�� INES KRASS�� XXN MR SECK

PN1689

Is this a document you have seen beforehand, or tell me if you haven't?‑‑‑Yes, I have.

PN1690

I am not sure if it's referred to in one of the superscript references, but - - -?‑‑‑I think we referred to a more recent document.

PN1691

So this is like an originating document which gives rise to the professional standards and you are probably familiar with it given your time at the university dealing with pharmacy practice. You will just see from the contents page, and I am using the page numbers with the small Roman numerals, (iii)?‑‑‑Yes.

PN1692

You will see that there are standards in relation to clinical and pharmaceutical services in a whole range of topics?‑‑‑Yes.

PN1693

Were you involved in the preparation or development of these standards at all, Professor Krass?‑‑‑No, I was not.

PN1694

You will see that there are some aspects of the CPS which appear to be dealt with in the professional standards in 1999 like DAAs, comprehensive medication reviews, comprehensive pharmaceutical care, liaison pharmacy and things of the like. Do you see that?‑‑‑Yes. I'm � I'm � well, I can't see it specifically.

PN1695

No, that's all right, I can take you to the page - - -?‑‑‑No, but I'm aware � I guess this is aspirational, this is what � this was what was � this was a vision for the competencies required by pharmacists if they were to deliver these services. I contend that at that time they were not being delivered, because there was no mechanism to encourage them to actually implement them.

PN1696

When you say it was aspirational and no mechanism to encourage you're basing that not on the literature review, but based on your knowledge as a professor?‑‑‑Yes, and other research that I've done. So I've published a lot of research in this area.

PN1697

Let me just go to some aspects of it and you can tell me - - -?‑‑‑Sure.

PN1698

- - - tell me if I am right or wrong. The fact that standards exist in these areas, and you've described it as aspirational, would it also be fair to say that there was some people who were doing these things, but it may not have been as common because of funding?‑‑‑It was negligible I would say.

***�� INES KRASS�� XXN MR SECK

PN1699

Is there literature showing that that was negligible at the time?‑‑‑I would say it's my � I'm just trying to think � yes, probably there is, there probably is some literature.

PN1700

If you want to do a work value comparison between what was happening in 1998 and what's happening in 2016 it would have been relevant to refer to the literature in your report?‑‑‑I think there's � there is not � I mean � I'm just trying to think � I don't think there was � there was a major survey done, but I think it was post that date.

PN1701

So would it be then fair to say there was no literature indicating whether or not these services were being provided; I think we agreed that - - -?‑‑‑I wouldn't say there's none, there's probably some literature, yes. There would be a paucity of literature.

PN1702

A paucity, but I gather given that the focal point of your report was to compare 1998 to 2016 if that literature existed you would have referred to it in your report. I couldn't find it, so I assume there's no literature?‑‑‑There's no � well, it's nothing to speak of.

PN1703

VICE PRESIDENT HATCHER: Just so I understand this point, are you saying these standards or this document was setting standards for a range of functions which by and large pharmacists weren't actually doing at that time?‑‑‑Yes.

PN1704

So for example health - - -?‑‑‑No. Yes, sorry, go on.

PN1705

So for example number 1 is health promotion, you say by and large they simply weren't doing it?‑‑‑Well, they were probably doing some aspect of it, but it was not � it was not � it's a little hard to explain this, but I think at a minimal level, can I put it that way. It was not a recognisable activity in pharmacies. There were some health promotion components. For example there was the self-care program which was a program that was � that came from the Pharmaceutical Society and there were pharmacists who actually had the self-care cards in the pharmacy and some were distributing them. So there was some activity, okay, but I wouldn't say that it was universally practiced.

PN1706

I am just trying to make a distinction here between whether the function was being done in some unstructured unstandardised way or whether it was just not being done at all?‑‑‑Very unstandardised, and very - - -

PN1707

So it was being done in some fashion?‑‑‑Yes, that's right, in some fashion, but not being paid for. There was no � there was no direct remuneration for this, for any health promotional activities.

***�� INES KRASS�� XXN MR SECK

PN1708

When you said paid for you meant funded?‑‑‑Funded, is not funded. In fact the pharmacist actually had to pay for the self-care cards.

PN1709

MR SECK: The Vice President took you to just the issue of health promotion, but there are obviously other issues which fall within the rubric of CPS?‑‑‑Yes.

PN1710

Would you say in the same way that things like comprehensive medication reviews, comprehensive pharmaceutical care was being provided by some people, but just in an unstructured way and not remunerated?‑‑‑I think it was very � I think it was very minimal, although there's not � there's no literature to tell us this, okay, so � and I mean from my own experience and knowledge of networks it was minimal.

PN1711

So I am clear on this your assertions that it was minimal is not based on academic research or any literature, but based on your anecdotal experience speaking to other people?‑‑‑Well, some � I'm just � there is some � there is probably a very small amount of literature, but it wasn't � it wasn't focusing on answering this question specifically if you will.

PN1712

I think you said in answer to one of the questions asked by my learned friend Mr Irving that you had been with the university since 1993, so you haven't been practicing in the field since at least from 1993 onwards, would that be fair?‑‑‑As a pharmacist?

PN1713

As a pharmacist?‑‑‑No, I haven't been practicing as a pharmacist, but I have been in very close contact with many pharmacies.

PN1714

Many pharmacies?‑‑‑Yes.

PN1715

I want to put that aside for the moment, so close that. Go to page 119 of your report. You will see there's a heading "CPS offered in Australian community pharmacies" about halfway down the page and you say:

PN1716

Overall from table 3 - - -

PN1717

And table 3 was the table which we took you to beforehand in part that sets out the various CPS services.

PN1718

- - - a range of CPS have become characteristic of community pharmacy practice in Australia.

***�� INES KRASS�� XXN MR SECK

PN1719

When you use the word "characteristic" are you saying that it generally reflects services which are provided by all pharmacists or some pharmacists or something which can be done by pharmacists?‑‑‑I think what it � what it refers to is that there are � there's a wide scope of services. Some services � there's certainly some services being provided, a core set of services if you will are being provided by most community pharmacies, and then there would be some pharmacies that are providing more.

PN1720

I think you deal with this in more detail in the semi-structured interviews and I will take you to the relevant material shortly?‑‑‑Sure.

PN1721

Then you say � when you say it's become characteristic what it doesn't tell us is when it became characteristic, and I think you accept that because there's a paucity of absence of evidence in 1998 we can't really say when it became characteristic, would you agree?‑‑‑But I think � well, we learn something about that from the � from the key stakeholders that they definitely attest to the fact that in the last 10 to 15 years they've been delivering the shift, there's been a very noticeable shift towards delivering cognitive pharmacy services.

PN1722

And the shift would be more pronounced in terms of structured organised provision of those services as opposed to something which was provided in an unstructured ad hoc way?‑‑‑Yes.

PN1723

So that's not to say it wasn't being provided, but not pursuant to the formalised programs which are funded under the CPAs?‑‑‑I would � well, I think they � I think what was being delivered was very minimal in the past. It was just � and linked directly to the dispensing, the action of dispensing. So there were some cognitive input if you will of the pharmacist at the time of dispensing. I don't think that anything beyond that was done by many pharmacists at all.

PN1724

When you say I don't think it was done - - -?‑‑‑It wasn't.

PN1725

- - - and minimal, I think you said beforehand there had been no literature on it - - -?‑‑‑Well, there's minimal literature, but it was certainly � from observational studies � I have done � you know, I've done research prior to this. I mean I've done research starting from 1993 if you will, and at the time the first � the first survey that we did of consumers coming from a community pharmacy suggested that all that they were receiving was just counselling around the medicine itself. There were no other services being offered at the time.

***�� INES KRASS�� XXN MR SECK

PN1726

When you say the surveys are these surveys referred to in your report?‑‑‑No, I don't think they � well, it's prior to 1998, and I'm talking about there were � there was work done in 1994 and subsequently I think in 1996. They're not actually referred to in the literature, but I guess that I can tell you that - - -

PN1727

Sure. Putting aside it's not in the report what it doesn't tell you is what's being done in 1998?‑‑‑Specifically in 1998 I don't think that there was a study that was specifically � that was specifically published in 1998, but over the period between 1993 and 1998 I did some of my research, you know, that was conducted suggested that there were no cognitive pharmacy services being delivered as we understand them in light of the definition that I've given you for cognitive pharmacy services.

PN1728

When you say in light of your research is this published research?‑‑‑Yes, it is published research, yes.

PN1729

I would have thought it would have been relevant to put it in your report if that demonstrates the change in work value between '98 and 2016, and it's not a criticism, I'm just wondering - - -?‑‑‑Okay. Well, perhaps so, perhaps so, but it hasn't been included.

PN1730

It hasn't?‑‑‑But I can � I can provide � I can provide references if you wish.

PN1731

The references are surveys, is that right?‑‑‑Yes, that's correct.

PN1732

I might ask you to provide that later to the Commission?‑‑‑Sure. Sure. You've got a copy of my CV?

PN1733

Sure. I mean I'm happy for you to go through your CV and identify it later?‑‑‑No, no, well I can do it later for you if you wish.

PN1734

That's fine, we might do it later. I am really basing it on your report at the moment, so you can understand - - -?‑‑‑Sure. No, I understand. Yes, that's fine.

PN1735

So if we go then to skills and training which you refer to?‑‑‑Yes. Which page are you referring to?

PN1736

So we are talking about page 119, sorry 118 to 119?‑‑‑Yes.

***�� INES KRASS�� XXN MR SECK

PN1737

I think you refer to training, do the pharmacy program � this is at the top of page 119 � intern training, and then post registration training. I think you were talking about training in a formalised way - - -?‑‑‑Education, yes.

PN1738

- - - as opposed to self-directed learning?‑‑‑Yes, sure. Yes.

PN1739

Or learning in an informal way by reading journals - - -?‑‑‑No, it's not informal training, it's � we're talking about the education of pharmacists, okay, in order to become registered pharmacists. So it's what's involved at the undergraduate level, at the intern level. So pharmacy � to become a registered pharmacist you have to undertake an accredited undergraduate degree which can be either a Bachelor of Pharmacy or in these days a Master of Pharmacy, and then that has to be followed by a period of internship training which has certain requirements linked to that, and there's a board exam that pharmacists actually have to take at the end of that training to demonstrate their competence. So it's a five year - for someone undertaking an undergraduate year it's a five year � a five year education program if you will to become a registered pharmacist. And not only that you have to remain up to date and they have to undertake continuing professional development, and that has become increasingly circumscribed and rigorous in recent years. There's much more required of a community pharmacist today in terms of demonstrating continuing competence than was the case let's say five years ago.

PN1740

Prior to more formal methods for training would you agree that much of the training which was done by pharmacists after the completion of their university degree and internship was experiential as well as self-directed?‑‑‑Sorry, I don't quite follow you.

PN1741

Let me probably do it in a few more questions and I apologise if I was a bit obtuse in asking that question. I think you have just referred to official, more formalised forms of training which pharmacists now have to undertake in order to - - -?‑‑‑Become registered.

PN1742

- - - become registered and to - - -?‑‑‑And maintain registered.

PN1743

- - - maintain registration. After the intern year the only formal training you have to undertake is now the mandatory CPD and any accreditation in order to perform work in respect of certain CPS?‑‑‑That's correct.

***�� INES KRASS�� XXN MR SECK

PN1744

In order to maintain registration previously prior to the introduction of CPD and in order to provide a professional service pharmacists would obviously need to keep up to date with new medications, new treatments, new aspects of pharmaceutical practice. Would you agree with that?‑‑‑Well, it was an expectation, but there was no � there was no way of enforcing that or understand whether it was being done.

PN1745

Assuming that pharmacists are re-registered because they can demonstrate their professional competence it would be left up to the individual pharmacist to make sure that their knowledge was up to date. Would you agree?‑‑‑I don't � I'm getting a little bit confused and - - -

PN1746

MR IRVING: Sorry to interrupt my friend, sorry, Professor. I don't think it was clear about what timeframe this requirement for continuing learning for re-registration was required.

PN1747

MR SECK: Prior to the introduction of compulsory CPD, and I apologise for that, and I think the introduction of compulsory CPD is something which has only arisen in recent years?‑‑‑Very recent, yes.

PN1748

So let me be clear about the timeframe, and I am grateful to my learned friend for raising it. Prior to the introduction of that � that's the questions I am asking � in order for pharmacists to maintain their registration and in order to provide a professional service pharmacists would have to undertake their own training and research to ensure that the advice and the performance of their duties was based on the latest research and the latest knowledge.

PN1749

MR IRVING: I object.

PN1750

WITNESS: I don't think that - - -

PN1751

VICE PRESIDENT HATCHER: Let's hear the objection.

PN1752

MR IRVING: There are two propositions there, to provide a professional service and maintain a registration. They're two separate questions which are rolled up into one.

PN1753

MR SECK: I will separate them. In order to provide a professional service � let's keep aside registration for the moment � would you agree that pharmacists had to do their own self-learning?‑‑‑Well, yes.

***�� INES KRASS�� XXN MR SECK

PN1754

In order to maintain registration there was no annual test that had to be undertaken, it would have to be brought to the attention of the regulatory authorities if there was someone who is performing unprofessionally; that's right?‑‑‑Correct.

PN1755

So the onus was placed upon pharmacists as professionals to make sure that their own knowledge and expertise was up to the requisite standard?‑‑‑That's correct.

PN1756

So the fact that there might be more formalised training programs doesn't necessarily mean pharmacists prior to the introduction of those formalised training programs didn't have those skills, it was just unstructured and left to the responsibility of the individual?‑‑‑It was left to the responsibility of the individual, but there was no requirement and therefore we have no idea of the extent to which that was being maintained.

PN1757

So it's hard to know whether or not this was new stuff people were learning or whether it was not it was formalising things that they already knew?‑‑‑(No audible reply)

PN1758

Can I now take you to page 141, Professor Krass. This is self-reporting by pharmacists about CPS services which are being delivered, and there are two reports here, there's the 2012 UTS pharmacy barometer, and the 2016 UTS pharmacy barometer?‑‑‑Yes.

PN1759

Are there any pharmacy barometers that predate October 2012?‑‑‑No. There was a national survey of pharmacists conducted by Con Berbatis. I think it was part � I think it was funded under one of the community pharmacy agreements. It may have been the third community pharmacy agreement. So it was between 2000 and 2005.

PN1760

So it's really hard I suppose because of the absence of barometers or similar - - -?‑‑‑Prior to that.

PN1761

Prior to that to ascertain what had been provided previously. Would you agree?‑‑‑Yes, sure.

PN1762

Just a few other things; it talks about pharmacies delivering the CPS as opposed to pharmacists. So that means there could be one amongst many pharmacists delivering the service, we just don't know how many pharmacists were delivering the services?‑‑‑We know � we know on average there's 1.5 pharmacists per pharmacy in Australia, so you can extrapolate from there.

***�� INES KRASS�� XXN MR SECK

PN1763

VICE PRESIDENT HATCHER: But does that include the owner?‑‑‑Yes. So the majority of pharmacies are still small scale operations.

PN1764

MR SECK: Do you know the sample size of these barometers?‑‑‑The barometers?

PN1765

Yes?‑‑‑No, I don't know off hand.

PN1766

Do you know the survey methodology which are used in those barometers?‑‑‑Well, it's a quantitative survey that's - - -

PN1767

Random or academic � I suppose I am asking you is that - - -?‑‑‑Yes, it's not � it's not my � I haven't � I have to be honest I'm not exactly sure, but I would imagine that they have a random sample of pharmacies and they survey them, yes. What the response rate is I have to be honest I actually � I don't know off hand.

PN1768

That's fine. Just looking at it, just about six lines down you say:

PN1769

Interestingly when examining sources of remuneration successful services were funded by government and consumers respectively. This indicates that there is value associated with the CPS from the perspective of both payers.

PN1770

So I think what you're looking at is not solely but chiefly those CPS services which are being funded under the PPIs, is that right?‑‑‑Well, they're not all funded. I mean a lot of � you know, the list here includes services that are both funded and unfunded.

PN1771

If you turn over the page I think there's a table which speaks for itself so I won't take you through that. Sorry, I want to ask you about one aspect of the table. It says - - -

PN1772

VICE PRESIDENT HATCHER: This is table 4?

PN1773

MR SECK: Table 4, yes, your Honour, "Provision of specific CPS in community pharmacies." When you say specific CPS that's CPS delivered in those pharmacies; that's correct?‑‑‑That's correct.

PN1774

As opposed to pharmacists who are providing it?‑‑‑No, it's delivered in the pharmacies, yes.

***�� INES KRASS�� XXN MR SECK

PN1775

Then go to page 143, Professor Krass?‑‑‑Yes.

PN1776

You refer to three - - -?‑‑‑Documents.

PN1777

- - - documents which are critical in terms of literature review and understanding the delivery of CPS. The first one is a 1998 report. The second one is the 1990-2002 report which is the Roughead � tell me if I'm pronouncing it correctly?‑‑‑Yes.

PN1778

So the first one is the Emmerson report. The second one we have described as the Roughead report, and the third one is, and correct me if I mispronounce it, Ben - - -?‑‑‑Ben Remo.

PN1779

Ben Remo?‑‑‑Yes.

PN1780

So it seems to me that just looking at it the first one, the 1998 one, the Emmerson one, would give you an indication of the services provided in 1998 or prior to that. The second one covers a much more extensive period between 1990 and 2002. So it potentially may capture things both before 1998 and after 1998. Do you agree?‑‑‑Yes.

PN1781

The last one seems to capture a period after 2002 up to 2005?‑‑‑Those � those are international, they're reviews of the international literature. They're not specific to the Australian context.

PN1782

Okay, I understand. So the only one which would be relevant to the Australian context would be the first one. Would you agree?‑‑‑No, not necessarily because that was probably an international review as well.

PN1783

I understand, so it's part of the international review, it includes Australia?‑‑‑Yes.

PN1784

Now if one was to do a comparison, and I know that you're not comparing a like with a like, it would be relevant to compare probably what was in the Emmerson report in 1998 - - -?‑‑‑Correct.

PN1785

- - - with the Australian aspects of the report in either � in probably the Ben Remo report because that seems to be after 1998. Would you agree?‑‑‑Yes.

***�� INES KRASS�� XXN MR SECK

PN1786

If you go after the number 3 in the middle of the page it says:

PN1787

The following table summarises from the two aforementioned substantial reports of systematic reviews of the literature.

PN1788

The table which you refer to, and I will come back to page 143 shortly, starts at page 145, and it seems to me the two reports you're comparing are the number 2 report which is the Roughead report and the Ben Remo report in 2005. Do you accept that?‑‑‑Yes.

PN1789

If we do a comparison between 1998 to 2015 wouldn't it have been useful or relevant to refer, at least in this table when doing a comparison, to the 1998 report?‑‑‑There are relevant key findings from 1990 to 2002.

PN1790

I accept that. I think what you accepted beforehand is that covers both before and after 1998?‑‑‑Yes.

PN1791

So it's hard to know whether or not - - -?‑‑‑But I guess the thing that we have to understand is that what these tables are demonstrating is the research that was conducted. It's not necessarily � it doesn't reflect practice, okay. They're talking about trials of different services, okay, and so it's not about what was actually, you know, at a routine level if you will, it's about the research that underpinned, I guess, investigation around delivery of cognitive pharmacy services. So I don't think we can take it as indicating what was being delivered in community pharmacy.

PN1792

So in a way this part of the report is not directed to answering the question you were asked?‑‑‑No, not really.

PN1793

This was really � the heading you use here is "Economic clinical and humanistic outcomes of CPS"?‑‑‑Yes. So that refers to � so when � when you're conducting health services research the requirement is that you show clinical outcomes, that you show humanistic which are quality of life, and economic outcomes. So it's really � it's very much grounded in the research that is seeking to generate evidence that these services can make a difference and that they're cost effective. It doesn't reflect what's actually happening in practice.

PN1794

And it doesn't reflect the work value definition which I took you to earlier, that is the kind of work which is in fact being performed by pharmacists in practice?‑‑‑No, not really, no.

***�� INES KRASS�� XXN MR SECK

PN1795

So we can ignore all this part of the report in answering that question?‑‑‑Yes.

PN1796

Would that be fair?‑‑‑That's fair.

PN1797

Obviously that table is very long and I won't take you � now we can ignore that table � I want to take you to "Limitations of the literature review" which is � unfortunately it doesn't have a page number, but it's page 186?‑‑‑I have it here, "Overall review limitations". Yes.

PN1798

VICE PRESIDENT HATCHER: What is it?

PN1799

MR SECK: Page 186. You say in the second sentence, Professor Krass:

PN1800

The literature searches were conducted systematically. Although the literature searches were conducted systematically it should be noted that this is not a systematic review of the literature.

PN1801

What do you mean by that?‑‑‑Okay. So a systematic review of the literature has a very specific connotation and it implies that it's � it refers to the comprehensive nature of the literature review. The search can be conducted, you know, according to a logic, but it may not capture the entire spectrum. So it's not a systematic review in the understanding in the published literature. It would not � it would not be a systematic review, but the review � the strategy, the research strategy that we used was systematic, it had certain parameters, but it can't be considered a systematic review.

PN1802

I think we talked about some of the parameters that you would have used beforehand, so there would have been a time parameter?‑‑‑Yes.

PN1803

What were the other parameters that you - - -?‑‑‑It would be terms, search terms.

PN1804

Search terms?‑‑‑Yes.

PN1805

And do you recall the search terms that would be used?‑‑‑It would be things like cognitive pharmacy services, pharmaceutical care, medication review, professional services. There's a range of synonyms if you will that would reflect � I think the search strategy is actually here. So in appendix 1 we have � so the search was done in Medline which is one of the major databases, so you can see actually in sequential steps the terms that we used.

***�� INES KRASS�� XXN MR SECK

PN1806

I understand. The database strategy is appendix 1 and you set out the search terms that you used?‑‑‑Correct, yes.

PN1807

All right. I didn't pick that up, so that's helpful?‑‑‑And we searched all the key databases that would be relevant to this area.

PN1808

When you say key databases those are pharmaceutical databases?‑‑‑Well, there's Medline, International Pharmaceutical Abstracts, PubMed, and they are, I guess, the main � and Cochrane databases as well � they're the main areas where we would find publications relevant to this topic. There are many, many different databases, but these are the ones that are relevant for pharmacy research, and we repeated the same strategy in each of the � in the search in each of the databases.

PN1809

You say � this is the last paragraph on page 186, Professor Krass?‑‑‑Page 106, yes.

PN1810

The first sentence:

PN1811

When focusing on the Australian context the components of CPS currently provided - - -

PN1812

?‑‑‑Sorry, my 106 - - -

PN1813

VICE PRESIDENT HATCHER: Page 186, is it?

PN1814

MR SECK: Page 186?‑‑‑Sorry, I misheard.

PN1815

Sorry, pardon me, Professor Krass, 106, the last paragraph?‑‑‑Yes. This is in the limitation section. Is that what you're referring to?

PN1816

Yes. In fact I might actually take you to the middle paragraph. It says:

PN1817

By examining evidence generated from systematic reviews of literature depending on their scope they may include studies in CPS that are not widely implemented.

***�� INES KRASS�� XXN MR SECK

PN1818

Would it be fair to say that where the literature talks about CPS it doesn't talk about whether or not in practice they're being adopted in a wide range way. So it may be indicative of a few people, some pharmacists or many pharmacists adopting it, we just don't know?‑‑‑Well, that's right, because most of the � most of the studies that are included in the literature review are focusing on research, their trials if you will that are trying to generate evidence that the pharmacist can actually make a difference. Yes, so � whereas, you know � it probably includes some that have looked at surveys of what pharmacists are actually doing, but the majority of them are actually clinical trials, or trials if you will, that have actually investigated whether your pharmacist deliver these particular services it makes a difference and it's cost effective. So it's trying to generate a body of evidence if you will to influence policy.

PN1819

And of course I think as you acknowledged earlier, Professor Krass, because the literature review embraced both Australia and international studies you would have to distinguish between them?‑‑‑Sure.

PN1820

And the literature in the Australian context is much more limited?‑‑‑Yes. Well, most of the bulk of the literature comes from the US, yes.

PN1821

If you go to the last paragraph which I was taking you to before is:

PN1822

When focusing on the Australian context the components of CPS currently provided in community pharmacies in Australia that are not remunerated by established systems such as CPA, i.e. CPS paid for by consumers (indistinct) in the service may vary between pharmacies.

PN1823

Do you see that? This is the first sentence of the last paragraph?‑‑‑Yes, I do.

PN1824

I gather from that what you're saying is that if it's not � the basis upon which your report proceeded is if it's remunerated it indicates a widespread adoption of CPS, but where it's not remunerated you just can't tell?‑‑‑Well, yes.

PN1825

And the inference you draw, or not the inference, but the basis upon which you seek to draw the conclusion that it's widespread is the fact that pharmacies receive funding for the CPA CPS services?‑‑‑The claimed funding.

PN1826

The claimed funding?‑‑‑So we know that they've been very heavily utilised, they have been � the services that have been funded have been taken up on a large scale.

***�� INES KRASS�� XXN MR SECK

PN1827

If you go to page 187 you say in the second last paragraph, and I will take you to the earlier parts shortly, it says:

PN1828

Thus new emerging evidence in relation to the work value of community pharmacists is expected in the near future that is specific to CPS provided in the Australian context.

PN1829

I think you're referring to the fact under 6, CPA, clause 6.1.3, there is going to be an assessment as to the cost effectiveness?‑‑‑Correct.

PN1830

So when you talk about work value there you're not talking about nature of the duties or the skills and responsibilities, but you're talking about the economic value relative to the cost. Is that right?‑‑‑Yes.

PN1831

Go to the conclusion which is page 188. You say:

PN1832

The roles and responsibilities of the community pharmacist have expanded in the last 20 years, but the movement away from dispensing oriented roles to increase in CPS provision in community settings.

PN1833

Do you accept that is not a conclusion which can be derived from the literature because we don't know what was being done 20 years ago based on the literature?‑‑‑Well, there's � I think it's conclusion that � there is some literature actually that tells us that not much was being done beforehand, so I think that's probably not reasonable to say that there's no underpinning literature.

PN1834

I think we went through - - -?‑‑‑Yes, sure.

PN1835

- - - the literature which existed 20 years ago. So I think you accepted you weren't aware of any literature other than perhaps some surveys in '93 and '96 which are not referred to in this report. So if this is a literature survey which is being undertaken in part 1 and this is the conclusion you're seeking to make from that literature would it not follow that this conclusion in the first paragraph is perhaps overstating it because it's not derived from the literature?‑‑‑I guess it's derived from literature plus other sources, other sources of � no, I think it is derived, it is derived from the literature, because what we see � what we see is this escalation of, I guess, research activity and investment in testing these services. So that in itself shows that there is a move towards expanding the role of the pharmacist and trying to develop evidence for that. So there's been a huge, I guess, upscaling of this activity, so I would � I would argue that that actually demonstrates that there is a shift if you will towards that.

***�� INES KRASS�� XXN MR SECK

PN1836

So it's not direct evidence, but it's an inference to be drawn from the fact that there's more academic activity. The fact that there may be more academic activity focus on the area could be a reflection of a whole range of different factors. Besides the increase in role and responsibilities it could be that there's more funding in the area. Would you accept that?‑‑‑There hasn't been funding.

PN1837

I am not talking about academic - - -?‑‑‑Well, funding of research. There's been some research funding, yes.

PN1838

It could be that there's simply more growing academic interest in CPS which has developed over time. Would you also agree with that?‑‑‑Yes, I would agree with that.

PN1839

The fact that there is increased academic activity in that area can be explained by other factors besides the fact that this is an increasing role and responsibility of community pharmacists?‑‑‑But there's � I mean I think you've got to consider the fact that this, I guess this flurry of research and testing and so on of these services has depended on cooperation from pharmacists, they wanted to be involved. It demonstrates an interest and a desire to expand the scope of practice. So they have been involved, they haven't � this hasn't been done in a laboratory, this is actually being done out in the field, so pharmacists have engaged with this � with, you know, a plethora. I mean under the third community pharmacy agreement we had a huge amount of money invested in research and development. So all of these projects involve pharmacists saying, "Yes, I'll do this. I want to be involved." So what we see is that there has been, you know, a very enthusiastic uptake of the idea. Not the idea, of involvement in expanding � you know, getting involved in expanded roles. So I think that it kind of refers to that as well, but there is a genuine interest in the � in the profession to become involved and to actually expand their scope of practice if you will.

PN1840

So would a fairer way of putting the conclusion, and you tell me if you accept this proposition, is that the level of interest within - - -?‑‑‑And activity, because they've participated. I argue that there have been � if you look across � if you look at the research that was done under the sixth � sorry, under the third and then subsequently the fourth community pharmacy agreement it involved huge numbers of pharmacists.

PN1841

Let me just put it to you again and tell me if you accept it. The level of interest and participation of community pharmacists in the research trials is indicative of an increase � sorry, the level of interest and participation in those trials in relation to the roles and responsibilities of community pharmacists has expanded over the last 20 years. Would you accept that's a more accurate way and a fairer way of putting what you just said?‑‑‑Possibly, yes.

***�� INES KRASS�� XXN MR SECK

PN1842

Because there is no actual evidence of it, but it's an inference which you have sought to draw from the academic activity and the participation?‑‑‑Well, we now have � I mean we have to compliment that with the research that we undertook subsequently, so we actually have got � we've done � we've got the qualitative research, which actually attest this trend, and I have other research which I can again give you references to which actually supports this.

PN1843

So let's focus on this report for the moment, but I will come back to the second report shortly and the other � and the research, and I am nearly finished in relation to this report. You refer then in terms of how you have drawn your conclusions. This is the fourth line:

PN1844

Changes to legislation and funding in Australia have aided the facilitation of the CPS provision and accessibility of these services to consumers in the community settings.

PN1845

So would it be fair to say that the fundamental aspect of you drawing the conclusion is firstly changes in legislation, and secondly funding?‑‑‑Yes.

PN1846

But not necessarily observation of like this happening in practice?‑‑‑Well, it's not direct of, but we know from � the statistics tell us that pharmacists actually have taken up these services so that they exhausted the funding for HMR and MedsCheck under the fifth community pharmacy agreement. So it's been � there's been a very, very substantial uptake of these services.

PN1847

But as we accepted beforehand funding is only limited to a few programs, not all the programs?‑‑‑No.

PN1848

That's the first thing, you would agree with that, and secondly funding may be indicative, it may not necessarily reflect that it wasn't being done beforehand in a more ad hoc unstructured way?‑‑‑It wasn't being done beforehand, I can tell you.

PN1849

Well, again I have taken you back to the report, I think you accept there's no literature on that issue?‑‑‑Yes.

PN1850

And it's based on your anecdotal observations. Now, go to the next part which says:

***�� INES KRASS�� XXN MR SECK

PN1851

Funding arrangements under the CPAs have formalised and refined pharmacists skills into distinct target CPS, for instance with the emergence of MedsCheck.

PN1852

So I think the emphasis there is there were skills beforehand but it's now more formalised and it has become more refined, but that's not to say - - -?‑‑‑And documented.

PN1853

And documented, but that's not to say it wasn't done beforehand, it's just more - - -?‑‑‑There was no process for it to being done and there was no documentation system to assist pharmacists. It was very unstructured if it was being done at all.

PN1854

And the additional training which is now required is a prerequisite for getting the funding. Would that be fair?‑‑‑That's correct.

PN1855

That covers part 1 of the report. Your Honour, it might be a convenient time given - - -

PN1856

VICE PRESIDENT HATCHER: Yes, it is. All right, we will now adjourn for morning tea and we will resume in approximately 10 to 15 minutes.

<THE WITNESS WITHDREW�� [11.27 AM]

SHORT ADJOURNMENT�� [11.27 AM]

RESUMED�� [11.56 AM]

<INES KRASS, RECALLED�� [11.56 AM]

CROSS-EXAMINATION BY MR SECK, CONTINUING�� [11.56 AM]

PN1857

VICE PRESIDENT HATCHER: Yes, Mr Seck.

PN1858

MR SECK: Professor Krass, I am now taking you to exhibit 15 which is part 2 of your expert report which you prepared jointly with Dr Tong and Professor Aslani. Do you have that in front of you?‑‑‑Yes.

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PN1859

If you go to page 4 this is an executive summary of the report. I just want to take you firstly to the objectives which are set out at the bottom of the page. Looking at the objectives of the report there one thing which looking at I noticed that if you go to the letter of engagement which I showed you beforehand there's no reference to work value in the objectives of the report, given though what you were asked to do � this is annexure E and I will tender that document shortly � asked you to investigate changes in the work value and that was to be done in the second part of the report in semi-structured interviews. Page 4 of the report in terms of the objectives doesn't refer to work value at all?‑‑‑It refers to reimbursement and revenue.

PN1860

Am I to understand that the notion of work value that you were investigating in the semi-structured interviews was the reimbursement and revenue, just in response to your - - -?‑‑‑Yes. It's not specifically articulated in the objectives, but we did touch on work value as part of the investigation.

PN1861

When you say you touched on work value - - -?‑‑‑Yes, we did � it was one of the � it was one aspect of the interview, we investigated work value from the perspective of the key informers, their understanding of the value of their work.

PN1862

So when you say their understanding of the value of their work - - -?‑‑‑Yes. Well, from two perspectives, the value of their work to the community, but the value in terms of � it also links to the remuneration that they receive for the work that they undertake.

PN1863

VICE PRESIDENT HATCHER: Professor, I was just going to ask you that. In the objectives when you have used phrases like community pharmacists or just pharmacist I am a bit unclear whether you were referring to pharmacy practices or - - -?‑‑‑No, community pharmacists themselves.

PN1864

So when you talk about reimbursement and revenue how does that relate to individual employed pharmacists?‑‑‑Well, it's looking at the revenue, well I guess the payment. It actually covers both, it's the payment that individual pharmacists receive as well as the payment that the community pharmacy receives. It encapsulates both. Because this � this investigation was interviewing individuals, okay, and we were getting their perspectives of their own remuneration as well as more broadly the remuneration of community pharmacies, but the focus was predominantly on the individual.

PN1865

Thank you.

PN1866

MR SECK: When you say on the individual you mean pharmacists?‑‑‑Pharmacists, yes.

***�� INES KRASS�� XXN MR SECK

PN1867

Can I just unpack that proposition. I think you said that it was their own perception of how they valued their own work; that's right?‑‑‑Yes, and how their work is � and the value of their work, yes.

PN1868

And you did that by reference in part to the reimbursement and revenue received by community pharmacists, which is objective 2. I had it read, and tell me if I am wrong, reimbursement and revenue was referring to government reimbursement and revenue?‑‑‑But it encapsulates both. It's looking at what they, what the pharmacies receive for services and what individual pharmacists are paid. We investigated both of those facets.

PN1869

I should read in your report reimbursement and revenue as referring to in part remuneration and wages?‑‑‑Yes, correct.

PN1870

I will take you back to that issue shortly?‑‑‑Sure.

PN1871

So do I then ascertain that number 3 � I will come back to objective number 1, but objective number 3, objective number 4 are not relevant to work value?‑‑‑No.

PN1872

All right. Why did you investigate those issues if they weren't relevant to the brief that you were given?‑‑‑I guess they are interrelated though because the notion of whether or not these things are of value to the community links back to the � it has a relationship with the work value. So if what pharmacists are doing actually has an economic benefit or an outcome then it actually reflects back on the value of the work that they're doing.

PN1873

Just looking at a definition � I think you said beforehand you were familiar with the contents of the instruction letter which is annexure E?‑‑‑Yes.

PN1874

There's a definition of work value reasons to which I took you at the very start of the cross-examination?‑‑‑Yes.

PN1875

If you were investigating through semi-structured interviews the work value of the community pharmacist between 1998 and 2016 wouldn't a more direct way of dealing with it is to ascertain by the semi-structured interviews the kind of work they were doing, the level of skill and responsibility involved in doing that work and the conditions under which that work is done which is the three elements of how they define work value in the - - -?‑‑‑Well, we did explore � we did explore all of those in the - if you've read, if you've actually read the report.

PN1876

I have read it and I want to take you through it. So when you say you have explored all of those that's the central focus in fact of what you were required to do?‑‑‑Sure.

***�� INES KRASS�� XXN MR SECK

PN1877

Do you accept that?‑‑‑Yes.

PN1878

But it doesn't seem to me to be the central focus in terms of the objectives which are set out on page 4?‑‑‑Well, the central focus � we had to describe what services are, okay, we had to look at the scope of current practice, what is actually being done by community pharmacists. Under that � I guess according to how I've interpreted objective 2 is we were looking at reimbursement for the individual pharmacist as well as the pharmacist, and that encompasses the ideas. So we didn't use the word "work value" specifically, but we were � there was an intent there to look at the value of that work, and then the subsequent objectives were to demonstrate that what they deliver to the community is a value, therefore that should be reflected in how they � how their work is valued.

PN1879

Just so I understand, part of what you were asking them is to determine the value to the community - - -?‑‑‑Part of that, yes.

PN1880

- - - and the value to the community should be reflected in the assessment of their work value?‑‑‑Yes, that's right.

PN1881

And that was one of the primary means you were seeking to demonstrate work value in the semi-structured interviews?‑‑‑Well, it was one means. I mean this is all � this is all self-reported, okay, these are testimonies of the stakeholders. So this is how they � this is what they do, this is how they do it, what is the scope of the activities that they have to undertake, what value does that have and how are they actually paid for it. I mean to put it in a nutshell.

PN1882

When you say what value does that have, I think you said one aspect is value to the community?‑‑‑Yes.

PN1883

One aspect is how they value it. Was there any other benchmarks - - -?‑‑‑Another aspect is how it's valued in terms of their remuneration, you know, how are they rewarded for the work that they do.

PN1884

The enquiry was in terms of the third aspect the work value reflected in what in fact they actually receive as payment?‑‑‑Correct.

PN1885

And those are the three ways that you sought to assess work values, let me just be clear on this?‑‑‑Yes.

PN1886

Their own self-perception?‑‑‑Yes.

***�� INES KRASS�� XXN MR SECK

PN1887

Secondly their value in terms of the services they provide to the community?‑‑‑Correct.

PN1888

And thirdly the actual pay they receive?‑‑‑Mm-hm.

PN1889

And that covers how work value was considered in this report?‑‑‑That's right.

PN1890

Would you agree that doesn't necessarily match up with the definition of work value which you were asked to investigate in your letter of engagement?‑‑‑No, I don't agree. It says the nature of the work, the level of skill and responsibility and the conditions under which the work is done. So perhaps the conditions are not directly specified, but we did investigate the skill which is implicit in the range of activities that they undertake, so what level of skill, and what it is that they're doing.

PN1891

All right, let's go through that - - -?‑‑‑And the conditions I interpret also as how much they're paid, what their salary is, how are they remunerated.

PN1892

It's a bit circular would you agree, Professor Krass, that it's the purpose as you understood it looking at the invest report is to determine the work value and whether or not there has been any changes in work value to determine the appropriate wage levels of pharmacists to look at the wage level they're in fact being paid to assess that work value. There's a circularity in that proposition, would you agree?‑‑‑Well, no, not entirely. I think the notion is that we were coming from the understanding is that the salary levels have not changed; in fact they have declined as I understand it. They have declined very significantly, and yet pharmacists are being expected to do more. The scope of their activities, the skill required to actually execute those activities has increased and changed over time, and that has not been reflected in the remuneration that they've received, and I would argue beyond that, if I might indulge you, that the community pharmacy agreements have delivered remuneration directly to the community pharmacy, but there's been no commensurate payment to the pharmacists themselves. So the employee pharmacists have been expected to do that � to expand the range of activities that they deliver, but that has not been reflected in any change to their salaries.

PN1893

When you say you would argue you're advocating that as a position or are you advocating that as the outcome of the semi-structured interviews?‑‑‑That's what I found out from the interviews, yes.

***�� INES KRASS�� XXN MR SECK

PN1894

The other thing that you were required to do was compare 1998 to 2016, which would mean you would need to get evidence from the semi-structured interviews to what people were doing in 1998. Would you agree with that?‑‑‑Well, if it doesn't exist I couldn't do it retrospectively could I.

PN1895

I am not asking you � but what you can ask people is what did you do in 1998 and what - - -?‑‑‑Yes, and we did that, we did cover that. It's covered in the interviews that there are testimonies to say we're doing � you know, that pharmacists were very, very specific about the fact that they were being � they were doing much more today than they had done previously, and that they were expected � you know, there was an expectation that they would deliver a broader range of services and � yes.

PN1896

So when you say this is what they did previously do you say that the question was asked of them, because I want to take you to what I understand the questions to be, "What did you do in 1998"?‑‑‑We didn't � I'm sure that it wasn't phrased as 1998. What they have testified is that in � in I guess the last, it's probably referring to the last five to ten years their scope of practice has changed. It's not � it doesn't have a specific date defining it, but there's a very clear message that that has been the case, particularly linked to the introduction of remunerated CPS. So now pharmacists are being � are being, or are delivering services like MedsCheck, like clinical interventions. These have only been around for the last ten years, they haven't been there previously.

PN1897

If we are doing a semi-structured interview to ascertain the difference between what happened in 1998 and what happened in 2016 or '17, which is the date of the interviews, you would need to have people working in 1998 as part of your sample size, right?‑‑‑Yes.

PN1898

So just going to the methods which are used for selecting and the participant demographics - - -?‑‑‑Yes.

PN1899

So firstly the methods for selection as set out on pages 5 and 6, and so as I understand it there was an invitation sent to pharmacists, but they had to be a PPA member in order to be invited; that's right?‑‑‑We did � we have two different approaches to recruiting people. We sent out a letter to the PPA membership. We also use what's called a snowballing sampling approach where we approach people that were known and asked other people, asked them to recommend others if you will, so we recruited our sample in two different ways.

***�� INES KRASS�� XXN MR SECK

PN1900

Do you agree that's not a randomised sample size?‑‑‑Random � random sample is � a randomised sampling approach is not appropriate for qualitative studies. What we used was a maximum variation sampling approach, which is to have a sample which reflects the broadest range of, I guess, age groups, experience, you know, position in the pharmacy and so on, so that we could get a broad spectrum of experiences and I guess informed � or information that would hopefully cover the spectrum, and that's � that's the recognised approach that's relevant in the context of qualitative research.

PN1901

So you need to have a broad range of terms of demographics - - -?‑‑‑Yes, that's right.

PN1902

- - - even though it may not be random in nature?‑‑‑That's right.

PN1903

Let's go to paragraph 23 and look at the demographics. So you have a sample size of 25 as I understand it?‑‑‑Yes.

PN1904

But the random - - -?‑‑‑Please don't use that word, random is not � is not relevant. What you're trying to do is capture the spectrum of experiences and attitudes.

PN1905

I am not suggesting it's random. As you explained to me it's not random?‑‑‑Yes.

PN1906

But if you look at the demographics there's an age range which is set out, and a large proportion of them are 25 to 44. So I gather some of them probably within that age bracket wouldn't have been working in 1998, do you agree with that?‑‑‑Some of them, but some of them would.

PN1907

We just don't know, do we, from that?‑‑‑No, not exactly.

PN1908

And it's not apparent to me when they started their pharmacy course or how long they had been working other than looking at the last one which is number of years of practice. Do you see that?‑‑‑Yes, I do.

PN1909

So it seems to me if you're comparing between what someone would have been doing in 1998 and what someone would have been doing in 2017 you have to exclude people less than five years. Do you accept that?‑‑‑Yes. Yes.

PN1910

You have to exclude people between five to ten years. Do you accept that?‑‑‑Well, not � maybe in terms of comparison, but you can certainly � they're still valid � they can give valid accounts of what the current practice is.

***�� INES KRASS�� XXN MR SECK

PN1911

And I am not denying that they can't, what I am saying - - -?‑‑‑Okay, but we have nine who are above ten years.

PN1912

That's true, but there's a 20 year period between 1998 and 2017 and we don't know whether or not any of them have more than 20 years' experience. Do you agree with that?‑‑‑Well, no, not from � not from the data that we have there.

PN1913

One can perhaps speculate that some of them might have more than � knew what happened in 1998, and one way of doing it is to look at the age group, but again we don't know when they actually completed their degree and how long they had been in fact practicing, and in fact whether or not they were practicing in 1998. Do you accept all that?‑‑‑It's possible.

PN1914

We don't know it, do we, Professor Krass?‑‑‑No, we don't know definitively, but we do have � we do have a representation from that age group.

PN1915

Again there is no precise - - -?‑‑‑No, it's not precise, no.

PN1916

Evidence supporting that people were working in 1998 who participated in the survey. Do you accept that?‑‑‑Well, I - - -

PN1917

Other than perhaps when we read the material in which it indicates that they were employed prior to that?‑‑‑There are verbatim quote which tell you that there were people who were interviewed who had been working longer, who had been working for over 20 years.

PN1918

If you reduce the survey sample and exclude those people who can't talk about what happened in 1998, and we're guessing that there are some people amongst those who had more than ten years' experience (indistinct) who did in fact � who may have had, I should say, had experience in 1998. That's a pretty small � that's probably an insufficient sample size in order to draw safe statistical - - -?‑‑‑You can't draw any statistical - - -?‑‑‑You can't draw any statistical inferences from the statement, I'm sorry.

PN1919

Given that you drew from the PTA membership database you might not have this to hand, and tell me if you know this or you don't know this. Do you know, if I read out some names to you, whether or not those participants, those people - - -?‑‑‑I don't know.

***�� INES KRASS�� XXN MR SECK

PN1920

All right. So if I said to you, someone in the name of Cardin Le participated in the � you wouldn't know?‑‑‑I wouldn't know the names of the participants.

PN1921

And that's the difficulty with � you don't know the names but you're taking the representations that they made at face value in terms of the information they provided. Would you agree with that?‑‑‑Sorry, I don't - - -

PN1922

Let me withdraw the question?‑‑‑I don't know follow that question.

PN1923

I apologise. It's a confusing question and I apologise for that. So let's go to the semi-structured interviews. Using the page numbers on the bottom of the page, the protocols are set out on page 19 in part 2.4 of the report, and I gather that the interviews were conducted by Dr Tong?‑‑‑Correct.

PN1924

Would that be correct?‑‑‑Yes.

PN1925

And there were audio recordings of the interviews?‑‑‑Yes.

PN1926

Did you listen to the audio recordings, yourself?‑‑‑Professor Aslani listened to the interviews.

PN1927

Right. So the answer is, you didn't listen to it yourself?‑‑‑No, not directly, no.

PN1928

Were there written transcripts of the interviews?‑‑‑Yes. Yes, there are.

PN1929

Did you read any of the written transcripts of the interviews?‑‑‑Yes, I read some.

PN1930

But the process of verifying the accuracy of that, that was done by Professor Aslani, not you?‑‑‑Correct.

PN1931

Looking at the semi-structured interview protocol questions you'll see on page 20, you said earlier on that the questions which were asked would seek to derive what they were doing in 1998. Now just looking at those questions, and these are the core questions admittedly and not all the questions, it's not apparent to me that at least one of the core questions to be asked is, what pharmacists were doing in the past, let alone what they were doing in 1998. Do you accept that?‑‑‑That's not apparent from the questions there.

***�� INES KRASS�� XXN MR SECK

PN1932

And if it wasn't a core question you cannot guarantee a question was asked as to what was happening in the past, let alone what was happening in 1998?‑‑‑I think it could be inferred. Certainly in looking at the data we did cover the concept of what had changed over time. So you're focusing very, very specifically on 1998. We didn't frame it in that way.

PN1933

Okay, that's fine?‑‑‑But we were looking for the activities that they currently undertake and how it just � globally how they had changed over time.

PN1934

When you say, and I accept that you didn't ask about 1998 because that would have been impossible, at least for a significant number of folks - - -?‑‑‑People wouldn't remember.

PN1935

Not only they wouldn't remember, they weren't working in 1998. But it's not, as you say it, it's not apparent from the questions that you were even asking them to compare to an earlier point in time. So the fact that some people may have given evidence on that, would you agree would have been incidental to the core questions?‑‑‑No because what we have here are the core questions. What happened was that there would have been a series of prompts that were asked, as well. So that would start with an open ended question and then the interviewer, in this case it was Dr Tong, would have had follow up questions where she would have explored each of these topic headings, if you will, in more detail. They're not articulated there but that's the usual practice in conducting in-depth interviews, is that you start off with an open ended question and then you have a series of prompts where you explore that topic in more detail.

PN1936

Right, but you don't know for sure whether or not that was explored with every of the interviewees, would you agree?‑‑‑Well, if you read the transcripts it is obvious that it was explored.

PN1937

All right, and one thing I don't have obviously is the transcript, so you've read the transcripts?‑‑‑Yes.

PN1938

And you can satisfy yourself if it's produced to the Commission - - -?‑‑‑Yes.

PN1939

That each of the questions which were asked, asked for a comparison between the current situation and now? I'm not trying to trick you but - - -?‑‑‑No, you are trying to trick me but - - -

PN1940

No - - -?‑‑‑I can't � look, I can't guarantee it but I know that from reading the results it was clear to me that it was discussed in the interview.

***�� INES KRASS�� XXN MR SECK

PN1941

All right, well - - -?‑‑‑That it was volunteered in many cases that people, when they were asked about what they were doing, they referred back to how it's changed over time. That's the way in which it was captured, to my understanding.

PN1942

When you say you can't guarantee it - - -?‑‑‑Yes. Well, I can't, I'm sorry. I can't guarantee it.

PN1943

But there are transcripts which we can analyse to show that?‑‑‑Yes. Yes.

PN1944

Okay. And you have access to those transcripts, Professor Krass?‑‑‑Yes. Yes.

PN1945

And would you be willing to produce those transcripts for the Commission?‑‑‑I would have to ask. I don't � it would be my co-investigators. I - - -

PN1946

Okay, so you would need to get permission from them to - - -?‑‑‑Yes.

PN1947

I understand that each of these participants also signed an agreement?‑‑‑Yes, they did. It's a consent, yes.

PN1948

A consent agreement, okay. So let's go through the content of the interviews. So go to page 26, part 3.3. This is an overview of the services being provided by community pharmacist, do you see that?‑‑‑Yes, I do.

PN1949

And there's a table which sets out the findings, quite conveniently on page 29, so if I can take you to that?‑‑‑Yes.

PN1950

So these are questions which are asked in terms of the range of cognitive pharmaceutical services offered in by respective community pharmacies?‑‑‑Yes.

PN1951

Is your one in colour?‑‑‑No, it's not.

PN1952

Okay. So the one I have in colour, and hopefully the one which the Full Bench has, is in colour but there are green sections with ticks and red sections with crosses according to my version, and there's a split between 6CPA funded CPS and non 6CPA funded CPS, that's right?‑‑‑Yes, that's correct.

***�� INES KRASS�� XXN MR SECK

PN1953

And am I right in saying what's set out in this table, Professor Krass, is the participant's responses, and the participant numbers are set out in the left-hand column, as to whether or not the particular pharmacy, as opposed to the particular pharmacist, provided these particular services as of the date of the interview?‑‑‑Yes, that's correct.

PN1954

So the report is not indicative, or this table is not indicative of whether or not the interviewees themselves had provided those services, would you agree?‑‑‑The table doesn't represent that but clearly if the pharmacy is delivering those services, the pharmacist who's employed in that pharmacy would have been involved in delivering the services.

PN1955

That doesn't necessarily follow. A pharmacist, a paid pharmacist - - -?‑‑‑Not necessarily but it's highly likely, highly likely that � it says here that � the title of the tables is, an ongoing basis which would have some pharmacists involved, and that - - -

PN1956

I accept that and that's what I'm putting to you?‑‑‑Yes.

PN1957

At least one pharmacist would have been providing it?‑‑‑Yes. Yes.

PN1958

So if you go through just the table, because I think it quite conveniently shows some points, it would seem that as an overall proposition, and tell me if you agree, the range of services which have been provided as of � these are CPS service which have been provided as of the date of the interviews which extends over a period in 2017, the majority which are provided are either 6CPA funded, perhaps except for state(?) supply?‑‑‑Mm-hm.

PN1959

And the third column amongst the non 6CPA funded CPS which is BP/CVD - - -?‑‑‑Mm-hm.

PN1960

Now just looking at the key, and tell me if you understand this, "BP" stands for "blood pressure"?‑‑‑Correct.

PN1961

And "CVD" stands for cardiovascular disease?‑‑‑Disease, correct.

PN1962

And I think just in terms of numbers I think I just said "BP, CVD", but I think it would also be fair to say that a majority, 15 on my count, also provide "BG", which is "blood glucose"?‑‑‑Blood glucose, yes.

***�� INES KRASS�� XXN MR SECK

PN1963

And would you agree, just looking at the rest of it, pharmacies appear, according to this sample, in terms of non 6CPA funded CPS, in the majority are not providing those services other than the ones I've just identified?‑‑‑Yes, there are fewer pharmacies providing other services. But this was just covering the spectrum of potential services.

PN1964

Of course. And I think that's what you were doing. You were trying to cover the potential services that have been provided and ascertain whether or not in fact in practice - - -?‑‑‑Yes.

PN1965

At least, amongst this sample group - - -?‑‑‑Yes.

PN1966

Whether or not they have been provided?‑‑‑That's correct.

PN1967

And just looking at the numbers on the side here, because I just need to understand it a bit more, received(?) participant numbers � this is 14A, 14B, and one of them has a hash next to them � now I think what this means, and tell me if I'm correct, it means a pharmacist actually works at two pharmacies?‑‑‑Correct, yes.

PN1968

And so the pharmacist is giving, or the interviewee is giving evidence on behalf of two pharmacies?‑‑‑Pharmacies, yes.

PN1969

And that's the same for number 18 and number 21, as well?‑‑‑Yes.

PN1970

Okay. Now what this table doesn't demonstrate is whether or not these services were being � any of these services were being provided in 1998?‑‑‑Well, they could not have - - -

PN1971

Or some earlier point in time. So do you agree that this is reflecting what the situation is at the time of the interviews?‑‑‑That's correct.

PN1972

But not some earlier point in time?‑‑‑Yes. But the reality is, the 6CPA services were not available in 1998.

PN1973

I accept that?‑‑‑So they could � none of those services could have been provided in 1998.

PN1974

Not funded services, anyway?‑‑‑Not funded, no.

***�� INES KRASS�� XXN MR SECK

PN1975

But potentially unstructured services, we just don't know because this is looking at funded services?‑‑‑No, they would not have been provided.

PN1976

And in relation to non 6CPA funded services that's obviously a point in time but not a comparison. There's no data in terms of tables or any other material which would allow us to do a comparison in terms of point in time?‑‑‑No.

PN1977

Can I then take you to � I think the range of services are then dealt with � let's go through each of the services now which are dealt with in 3.4. So this deals with firstly, DAA's, dose administration aids?‑‑‑Yes.

PN1978

The evidence seems to reveal these things. Firstly, that it's been provided by pharmacies and � do you agree with that?‑‑‑Well, it's been provided by a pharmacist working in a pharmacy. It's still part of the work of the pharmacist who's working in that pharmacy, whether it's the owner or an employee.

PN1979

What it seems to suggest is that the pharmacist checks it but the technician actually, in some cases, dispenses it. Would you agree with that?‑‑‑It varies. Sometimes it's the pharmacist, sometimes it's the technician and then it needs to be checked, yes.

PN1980

And does the data reveal from your reading of the material, and tell me if you don't know or if it's not revealed, whether or not it's a technician who's doing the work or � in terms of packing or whether or not it's the pharmacist?‑‑‑It varies. Sometimes it's the pharmacist and sometimes it's the technician.

PN1981

But does it tell you numbers on the � - -?‑‑‑No, I can't tell you numbers, no.

PN1982

That's fine. I just wanted to check that. It says here, as well that:

PN1983

The DAAs are provided to both community based patients -

PN1984

And this is in the first paragraph:

PN1985

- supported by 6CPA funding and residents of aged care facilities not supported by 6CPA.

PN1986

Do you see that?‑‑‑Mm‑hm.

***�� INES KRASS�� XXN MR SECK

PN1987

You've said in answer to one of my questions earlier, Professor Krass, that the fact that there's funding indicates that this was being done. Now the fact that there also are non-funded parts at least for residents of aged care facilities may be consistent with the fact that it was being provided before funding became available. Would you agree with that?‑‑‑Well, it's directly paid for. It's paid for by the residents or by the nursing - by the aged care facility. So there's no government remuneration but it's being paid for by the patient.

PN1988

And so it could have been paid for previously, prior to the available government funding, to community based patients?‑‑‑Yes.

PN1989

If they paid for it on a fee for service basis?‑‑‑Yes, it's possible. Yes.

PN1990

Now go to MedsChecks which starts on page 34. If you go - there's a description of MedsChecks which is contained in the first paragraph and I won't read that to you but go over the page to page 35. You'll see that one of the pharmacists discusses - this is at the bottom of the page:

PN1991

The impact of the formal remuneration pathway available for MedsChecks on service quality.

PN1992

So there's an identification of a formal remuneration pathway and then the quote there describes the steps that need to be taken in order to obtain the remuneration. Do you see that?‑‑‑Yes. Yes I do.

PN1993

And so I think the steps are you need to complete some paperwork and you need to have the form signed by the patient in order to receive the remuneration. Is that your understanding?‑‑‑Yes.

PN1994

If you go over to page 37 at the top of the page there's a reference to one of the participants saying they:

PN1995

... continue to offer unofficial MedsChecks due to perceived duty of care of the pharmacist.

PN1996

And that's because, as I read it, the patient often is unwilling to sign the document. Do you see that?‑‑‑Yes.

***�� INES KRASS�� XXN MR SECK

PN1997

Do you know if there was any questions asked during the course of the interviews addressing unofficial MedsChecks that were being provided because of the perception of duty of care by pharmacists?‑‑‑I think that was volunteered. I don't think that was a specific line of enquiry.

PN1998

Now let's go to HMRs which is on the same page. I think here it says six people were accredited; six out of the 25 people say they were accredited to do it and I think your understanding is from your previous answers you have to be accredited to do the HMRs?‑‑‑That's correct, yes.

PN1999

That's correct?‑‑‑Yes.

PN2000

What's suggested here at the bottom of page 37 and the top of page 38 is that even though people are accredited there might be circumstances where they don't in fact do the HMRs. Was that consistent with any of the evidence that you read?‑‑‑Yes. Yes, it's possible.

PN2001

So even though people were accredited they may not in fact use their accreditation to provide those services?‑‑‑Well, it's a matter - the - an HMR has to be initiated by a general practitioner so if the - if a general practitioner doesn't - if they can't find a general practitioner who's - who wishes them to do an HMR then they can't initiate it themselves.

PN2002

Right, now go to page 39 and "Clinical interventions"?‑‑‑Yes.

PN2003

Now the evidence seems to be - and tell me if this was consistent - that:

PN2004

Clinical interventions were seen as a service ingrained in the practice of pharmacy.

PN2005

?‑‑‑Mm‑hm.

PN2006

So am I right in saying that the interviewees or some or the majority of interviewees - and tell me which ones - considered clinical interventions part of their regular job?‑‑‑Certainly delivering clinical interventions but not documenting clinical interventions. So the key difference, the key thing that has changed with the introduction of a remunerated process is that they actually are documenting their clinical interventions.

PN2007

And that - - -?‑‑‑Which implies that they have to reflect on that.

***�� INES KRASS�� XXN MR SECK

PN2008

I understand. So would that be consistent with this proposition, Professor Krass. That is, it has always been done as a regular part of the practice of pharmacies and pharmacists but in order to receive the remuneration the material difference is documenting it in order to claim the remuneration?‑‑‑No, I would argue that it's been done much more consistently because there's a structured process that facilitates it. It's not to say that pharmacists weren't identifying issues related to the prescription. That's part of their professional training, but I think they're doing it much more consistently and that's been enabled by the availability of a document, of an electronic documentation system which they're required to complete in order to be paid, but it's actually facilitating a much more efficient and effective process of documenting - of delivering clinical interventions, or of actually addressing clinical interventions if you will.

PN2009

You said this is what you would argue?‑‑‑Yes.

PN2010

Was it revealed in the interviews that - - -?‑‑‑Yes.

PN2011

- - - that was so?‑‑‑Yes.

PN2012

I'm just reading here in terms of you say it's done in a much more structured way?‑‑‑Yes.

PN2013

And that's an additional part. Besides documentation there's nothing to suggest in any of the feedback which is recorded here that it's any different because it's done in a more structured way?‑‑‑Yes but it says here - if you look at one of the quote - it says "especially when we're reminded about clinical ... you probe for things more and more and you become a better history taker". So the fact that they actually have to document it and have to think about it, it means - well, as according to this particular testimony that they're doing it in a - you know, they're likely - it's likely to be a more effective process.

PN2014

I understand?‑‑‑Okay?

PN2015

And I think the interviewee says there just from the quote on the top of page 40?‑‑‑Yes.

PN2016

"It's a reminder of how you should be practising"?‑‑‑That's right.

***�� INES KRASS�� XXN MR SECK

PN2017

So the skill set has always been there. It has always been done, but this is much more structured?‑‑‑Correct.

PN2018

Because it needs to be documented.

PN2019

MR IRVING: So perhaps my friend could clarify. When he speaks about "always" is he talking about from the time of the Egyptians or 1998 or since 6CPA?

PN2020

MR SECK: Sorry, at the time that this particular interview's taking place, yes.

PN2021

Can we deal then with "Staged supply" which starts at page 40. The person in the quotation which is immediately after the first sentence says:

PN2022

That's basically something that is needed to be done especially for certain S8 and opioid medication.

PN2023

When the person says it needed to be done, is your understanding that if you're going to provide professional services in relation to S8 medication this is a necessary part of providing S8 medication?‑‑‑But the state - well, no, I think what he's referring to there is that it strengthens the process. So they've always - pharmacists have always had to retain records of S8 medication but this - I guess the whole rationale for a staged supply is to prevent abuse, actually to prevent the patient from using it - from using excessive amounts of the schedule 8 substance. So the staged supply service if you will, its rationale is intended to do that but pharmacists haven't previously been able to do that. They've been given an extra level of responsibility under the staged supply process to provide a certain amount and then provide - you know, and then document what they're doing. So it allow - it enables a process of monitoring, if you will.

PN2024

And that monitoring is through the keeping of records?‑‑‑That's right, and encountering the patient the next time they come to collect their next dose.

PN2025

And in fact the quote on page 40 in the centre of the page:

PN2026

A staged supply just provides a good way for us to keep a record.

PN2027

It would be the case based on your experience - and tell me if it isn't - that some pharmacists would have kept records in any event to ensure that they provided professional services and there's no abuse of the system?‑‑‑They would just have - they would have complied with the law I imagine, and kept duplicates or kept copies of the prescriptions.

***�� INES KRASS�� XXN MR SECK

PN2028

Right, and so they would have kept records which would have enabled them to do that but perhaps not in the structured way that - - -?‑‑‑No.

PN2029

- - - is contemplated here?‑‑‑That's right. That's right.

PN2030

Okay, and then let's - - -?‑‑‑And I guess the other thing, if I might just interject here.

PN2031

Of course?‑‑‑All of this additional documentation that's kind of come into place, which is a really good thing because it's improving the quality of practice, it takes time. You know, it take - it's more - I guess it's - it has to be considered as part of the work, you know, of the scope of work that the pharmacist is doing. It actually takes time.

PN2032

When you say it takes time, it means it takes more time to do it for the purposes of the program?‑‑‑Properly.

PN2033

Because documentation - - -?‑‑‑Yes.

PN2034

- - - involves more time than simply perhaps keeping the dockets, which is what happened previously?‑‑‑Precisely.

PN2035

Okay, I understand what you're saying. Now go to part 3.5 which is - - -?‑‑‑Sorry, part?

PN2036

3.5 starting at page 41 which is - - -?‑‑‑41, yes I've got it.

PN2037

The non-6CPA initiatives?‑‑‑Yes.

PN2038

Now there's a lot more here, and I'm conscious of time so I'm just going to go through only some of them and not all of them?‑‑‑Okay.

PN2039

Now the first one is pharmacist-delivered flu immunisation, that is flu vaccination, starting at page 42?‑‑‑Yes.

PN2040

It says here:

***�� INES KRASS�� XXN MR SECK

PN2041

Pharmacist-delivered flu vaccinations were offered by pharmacies in a number of studies.

PN2042

Now this is an example of where pharmacies may have offered it but not all pharmacists were qualified to offer it?‑‑‑Well, they have to do special training. So they have to become accredited to be able to deliver a vaccination so it's - this is very recent. This is probably the most recent program that's actually been introduced so it's - you know, there's a kind of a gradual upskilling if you will of community pharmacists. So they - a pharmacy might just have one accredited person or they might have one accredited pharmacist, they might have several.

PN2043

Now go to "Blood pressure"?‑‑‑Yes.

PN2044

Which is one of the services which are provided by the majority of - - -?‑‑‑Yes. Yes. Yes.

PN2045

- - - the participants at their pharmacies or at the pharmacies at which they worked, which was non-CPA funded - - -?‑‑‑Yes.

PN2046

Or, sorry, non-6CPA funded?‑‑‑Mm‑hm.

PN2047

VICE PRESIDENT HATCHER: Is that page 44?

PN2048

MR SECK: Page 44.

PN2049

THE WITNESS: Yes.

PN2050

MR SECK: It seems to me there are different ways of providing the blood pressure checks and monitoring, some of which was provided by pharmacists, some of which was a self‑service option?‑‑‑Sure. That's correct.

PN2051

And just so I understand the self-service option, there's a machine?‑‑‑Yes.

PN2052

Which allows someone to assess their own blood pressure?‑‑‑Yes.

PN2053

That's right?‑‑‑Yes.

***�� INES KRASS�� XXN MR SECK

PN2054

And so it's not the pharmacist who's doing the blood pressure test, it's the patient who's doing the blood - - -?‑‑‑Yes, in that context. Yes, there are - they're both. I mean there are - and there's also - I mean there are two different purposes for blood pressure checks. One could be actually to screen someone for unidentified hypertension or it could be to monitor a response to treatment if they're already on anti-hypertensive therapy.

PN2055

And the report seems to suggest that pharmacists aren't always involved where there's a self - - -?‑‑‑That's correct.

PN2056

Did the interview - did you get information which would indicate when the pharmacists were involved and when it was self‑serve in terms of numbers? Is that something which you recorded?‑‑‑No. No, but I actually have data from other sources and again I can supply you with the additional references. I've done a lot of work in this area myself.

PN2057

When you say the other sources, that's in Australia?‑‑‑Published articles that - - -

PN2058

Right, in Australia?‑‑‑Yes, studies that have done - that have been done in Australia.

PN2059

And just so I understand, would the studies indicate there's a variability?‑‑‑Yes. Yes.

PN2060

So some people would have been doing self-testing, some of it would be pharmacy supervised?‑‑‑Yes.

PN2061

Or pharmacist supervised?‑‑‑Yes.

PN2062

It's the intern pharmacist who may do the supervision?‑‑‑Under supervision.

PN2063

Under supervision from the pharmacist?‑‑‑Yes. Yes.

PN2064

If we can go to "Blood glucose testing" on page 46, Professor Krass. As I understand blood glucose testing involves the use of a BG meter. Can you explain to the Commission what's a BG meter?‑‑‑Okay, blood glucose meter. So it's a device, so you use - you take a sample of blood from the finger, capillary blood sample, you apply it to a test strip and you put it into the machine and it reads out the blood glucose reading.

***�� INES KRASS�� XXN MR SECK

PN2065

Now it suggests here that it can be standalone testing or in conjunction with other checks. So standalone testing means just doing the blood glucose testing by itself?‑‑‑Sure. Yes.

PN2066

Okay, now this is - - -?‑‑‑And what's quite common now in a number of pharmacies is they offer what they call a health check, so it's a bundled set of screening where they would screen for blood pressure, for blood glucose, weight, cardiovascular risk et cetera. So a range of tests all bundled together.

PN2067

And what this suggests here is that there might be some blood glucose meters which are provided to patients which they administer themselves but they're counselled as to how they use the meters?‑‑‑Yes, so the - so particularly this applies to pharmacies who are agents of - who have I guess - or who are agents of Diabetes Australia or administer the NDSS scheme so - which entitles people with diabetes to have those certain subsidised - access to subsidised test strips et cetera. So pharmacies are often involved in educating people on how to use the machines. That's different from actually taking a blood glucose test.

PN2068

Would it be the case that sometimes once a patient was told how to use it for the first time they would come and do it themselves subsequently, or is it always - - -?‑‑‑They would take it home. It would be for self-monitoring of blood glucose at home, but they may bring the machine - they might bring their meter into the pharmacy to check it, to do a calibration test.

PN2069

Now let's go to - we'll skip over a few - - -?‑‑‑And additionally actually if I might just intercede there, there are some pharmacies that will have software, they will download the blood glucose readings from the meter and then they can use that as the basis for a disease management or monitoring service.

PN2070

And that's part of what we've been talking about beforehand?‑‑‑Yes.

PN2071

Sometimes it can be in conjunction with other services?‑‑‑That's right. Yes. Yes.

PN2072

Now go to page 49, Professor Krass, which is "Sleep apnoea"?‑‑‑Yes.

PN2073

Now as I understand it just from reading this - and tell me - I'm going to put a few propositions to you, that sleep apnoea testing involves the use of a machine which is taken home by a patient?‑‑‑Yes, that's right. Yes, Flow S. Yes.

***�� INES KRASS�� XXN MR SECK

PN2074

Instructions are given - - -?‑‑‑Yes.

PN2075

- - - by someone in the pharmacy?‑‑‑Pharmacy, yes.

PN2076

It may not necessarily be a pharmacist but it could be?‑‑‑Well, it's likely to be the pharmacist.

PN2077

Likely to be?‑‑‑Yes. They'd have to be - they have to have a, you know, a reasonable - a reasonably good understanding of the equipment and what it means et cetera. So they would have had to undergo training.

PN2078

So when you say a pharmacist would have to undergo training, it doesn't refer to training here but would it also potentially involve - so let me take it a step back. When you say training, it's training from the manufacturer?‑‑‑Yes, to understand the equipment. Yes.

PN2079

Right, and then those instructions are conveyed to the patient and it's the patient who undertakes the sleep apnoea - - -?‑‑‑Yes, they have to wear the device.

PN2080

- - - test device?‑‑‑They wear it overnight and - - -

PN2081

And when it's returned the data is downloaded and then sent off to a third party?‑‑‑Yes, that's correct.

PN2082

And it's the specialist who interprets the data?‑‑‑The diagnosis, yes.

PN2083

And then that's returned back to the pharmacist and the pharmacist produces that report to the patient?‑‑‑Yes.

PN2084

And that may lead to further - - -?‑‑‑CPAP - well, often - - -

PN2085

CPAP or (indistinct) - - - ?‑‑‑Yes if it's - if they're diagnosed with obstructive sleep apnoea then CPAP is a recommended therapy.

PN2086

Then let's go to "Compounding" on page 50 and page 51. The suggestion it that compounding services are offered in the pharmacy, some of their pharmacies?‑‑‑Yes.

***�� INES KRASS�� XXN MR SECK

PN2087

Now just talking from your general experience, Professor Krass, from maybe the 1990s to now have you read any reports or made any observations about compounding becoming - - -?‑‑‑A specialised service.

PN2088

A specialised service?‑‑‑Yes.

PN2089

Which is less available than it used to be?‑‑‑Well, it's a - it actually refers to a very specific type of compounding. So every pharmacy, every pharmacist is trained to do what's called extemporaneous dispensing so - but people who offer a compounding service have a special laboratory set up where they can produce a range of pharmaceutical products at a - you know, at - with particular characteristics which would not be possible in, you know, in the standard dispensary. So they're specialised products and it requires I guess an investment to set up the - you know, to set up a sterile section and, you know, to set up the - to have the - you know, the range of equipment that's required in order to produce these specific different dosage forms.

PN2090

Now if we go to "Wound care" which is on page 52?‑‑‑Yes.

PN2091

The evidence seems to suggest here that sometimes it's provided by pharmacists, sometimes it's provided by nurses. Do you accept that, yes?‑‑‑Yes - well, yes. Yes.

PN2092

Did the evidence in the interviews reveal a proportion of times that a nurse would provide it as opposed to a pharmacist?‑‑‑I can't give you - no, I can't give you - but it would mainly be pharmacists because there aren't nurses available in - you know, in many pharmacies.

PN2093

You're inferring that from the fact that most pharmacies wouldn't - - -?‑‑‑Yes.

PN2094

- - - be big enough to have a nurse?‑‑‑Yes, that's right.

PN2095

All right, well I think I've taken you through all the major ones I wanted to take you through amongst the non‑CPS services. I just want to now just take you to "Training" which starts at page 57?‑‑‑Which one?

PN2096

Page 57?‑‑‑57? Yes.

***�� INES KRASS�� XXN MR SECK

PN2097

Would it be fair to say that overall the interviews revealed that there's a diverse range of training which is undertaken by pharmacists, some of which is formal, some of which is informal?‑‑‑Yes, I think that's fair. Yes.

PN2098

And that in your experience as a professor generally reflects the kind of training which pharmacists have been doing since the 1990s, both formal and informal?‑‑‑Well, I think there's - I mean if we go back to the idea that there's now mandatory continuing professional development I think that there's - that pharmacists are undertaking more - many more structured type of training programs.

PN2099

And prior to the compulsory CPD - do you conduct any of the CPDs yourself, Professor Krass?‑‑‑I do my own CPD. I'm a registered pharmacist. I do. I deliver any - yes, well - yes I do. Yes. Yes.

PN2100

And did you deliver CPD before it was not mandatory, that is - - -?‑‑‑Just lecture. I mean what I'm currently involved in is I deliver online courses as part of a program, a university program called Graduate Certificate in Pharmacy Practice, which is recognised as continuing professional development. So I didn't do that beforehand, no.

PN2101

Okay so - - -?‑‑‑It's a relatively new program.

PN2102

So you've only started doing that once it became compulsory?‑‑‑Yes, I - in the past I have given lectures as part of, you know, pharmacy conferences and so on to - which counted as continuing professional development.

PN2103

But that wasn't obviously mandatory?‑‑‑And there wasn't necessarily any assessment associated with it. It was just I guess, yes, a series of lectures around a particular topic. Most likely it was something related to diabetes, which is my area of interest.

PN2104

Now I think the issue of payment which starts at page 72?‑‑‑Yes.

PN2105

One of the propositions that you advanced after the morning tea break, Professor Krass, was that one way of assessing work value - and this is one part which is addressed in your report - is the payment or remuneration that's received by pharmacists, community pharmacists but not the pharmacies themselves?‑‑‑Well, it could be both but - yes, but we're specifically addressing the community pharmacists themselves here.

***�� INES KRASS�� XXN MR SECK

PN2106

All right?‑‑‑Yes.

PN2107

Now page 72 onwards, just so I understand it, this talks about services for free and things like that. That's actually about remuneration and fees earned by the pharmacy not the pharmacist themselves. That's right?‑‑‑Yes, that would refer to what's happening to the - yes. Yes, I agree.

PN2108

And page seventy - I think I'll skip over that. Page 80, if you can go to that. Now I think you said beforehand another way of assessing value of the work of pharmacists is to look at the economic impact. That's right?‑‑‑Mm‑hm.

PN2109

And this part 3.13 starting at page 80 is the economic impact?‑‑‑Mm‑hm.

PN2110

Here it seems to be referring to "reimbursements for pharmacists' time associated with CPS provision"?‑‑‑Mm‑hm.

PN2111

When you talk about reimbursement of pharmacists' time are you talking about reimbursement from the employer?‑‑‑Yes.

PN2112

Now as I understand it employees - and tell me if this is your understanding - are getting paid on an hourly basis for the time they spend anyway, so they're getting paid for that, for performing the work of a pharmacist?‑‑‑Mm‑hm.

PN2113

What you're talking about in terms of reimbursement is the pharmacist getting a cut of the funding?‑‑‑Yes.

PN2114

Okay?‑‑‑Or a pharmacist being recognised for the additional scope of work that they're being asked to do. So they're getting the same salary that they were - or less than they were getting when they were purely fulfilling the supply and - role that was linked directly to the dispensing of medicines, whereas now there's a broader range of expectations but there's no commensurate recognition of that in their salaries. In fact they've - salaries have declined.

PN2115

And would it be the case that what was presented in the interviews is that the pharmacists believe they should get remunerated only for the time which they perform the provision of those CPS, CPA funded services - - -?‑‑‑No I think they - - -

***�� INES KRASS�� XXN MR SECK

PN2116

Or for all the time regardless of whether or not they provide it or not?‑‑‑All - I think - well, it's part - as you say it's part of the - it's part of their job. They're employed as pharmacists in a pharmacy but if they're being asked to do MedsChecks and diabetes MedsChecks et cetera, et cetera, that they're seen to add - you know, those services add - you know, add value and require a specific set of skills but there's no recognition of that in the salary that they're receiving.

PN2117

And when you say it adds value, the value which is added is the remuneration which is received from the government for the provision of those services. Do you accept that?‑‑‑Well, both. It adds - and it's add - and it's of value to the community. It's actually adding value to - you know, in terms of health outcomes.

PN2118

Okay so - - -?‑‑‑Both. I mean it encapsulates both.

PN2119

Yes but you keep - - -?‑‑‑And adding value to the income of the pharmacy because they're being paid.

PN2120

But in terms of what you're dealing with here at page 80, you talk about reimbursement for their time?‑‑‑Yes. Yes.

PN2121

So what you're talking about here is - - -?‑‑‑It says "salary".

PN2122

Salary?‑‑‑Yes.

PN2123

But for the time associated with the provision of the CPS service, not just generally?‑‑‑No I'm talk - I think it's - it refers to their general - the wages that they're receiving as employee pharmacists.

PN2124

But the way I read that sentence - and tell me if I'm wrong - is:

PN2125

Participants stated that the reimbursement for a pharmacist's time associated with CPS provision at present was insufficient.

PN2126

Which tells me it's limited to the time they're spending on CPS provision as opposed to their general duties?‑‑‑Well, I think that's probably referring to the remuneration that's available for CPS. It's - it encapsulates both, okay? And I think there's a sense that CPS are not adequately remunerated and that the pharmacists themselves who are - if they're, you know, in an employee context having to deliver these CPS, are not being adequately paid either. So it's both.

PN2127

I didn't read it as both?‑‑‑Okay. Well - - -

***�� INES KRASS�� XXN MR SECK

PN2128

But you can tell me which parts - because I read that as being limited to what it says there?‑‑‑Well, I think it depends what - the hat that the individual is wearing. If they're an employee - if they're a pharmacy owner they're probably speaking with respect to how much the pharmacy - you know, how much remuneration the pharmacy receives for a particular cognitive services. There are - both of those ideas emerge from the data. There's on the one hand it's the pharmacists claiming that the payment that's available for cognitive pharmacy services is insufficient but employee pharmacists are also claiming that they're delivering these services but they're not being - you know, the payment they're receiving does not recognise that there's been a change in what they're being expected to do.

PN2129

Can I take you to - I note the time, your Honour.

PN2130

VICE PRESIDENT HATCHER: How much longer will you be, Mr Seck?

PN2131

MR SECK: I think about 15 minutes.

PN2132

VICE PRESIDENT HATCHER: Is there re‑examination, Mr Irving?

PN2133

MR IRVING: At the moment one question.

PN2134

VICE PRESIDENT HATCHER: We might just keep sitting until we finish this witness.

PN2135

MR SECK: May it please.

PN2136

Now I want to go through the perceptions of changes in the practice?‑‑‑Yes.

PN2137

Which starts at page 83, Professor Krass?‑‑‑Sure. Yes.

PN2138

If you go to page 84 you refer to remarks made, about halfway down the page:

PN2139

It was remarked that -

PN2140

Quote:

***�� INES KRASS�� XXN MR SECK

PN2141

"The ethos behind what we do is the same but it has evolved in that time so we've got better at what we do, we've got better at service delivery and we've got better at identifying and meeting the needs of customers."

PN2142

Do you see that?‑‑‑Mm‑hm.

PN2143

Now that would seem to suggest to me, at least with this participant, that these things were being provided beforehand but they were being provided at an inferior quality and that over time the quality standards have increased. Would you agree with that?‑‑‑Yes, that's a reasonable interpretation.

PN2144

And is it consistent with other interviewees' evidence that these were services being provided but it's now being provided at a better quality - - -?‑‑‑No, not - in some cases yes, in some cases no.

PN2145

And I think going down to the bottom of page 84 it says:

PN2146

It was also acknowledged that there may be differences in the quality and types of services offered between pharmacies.

PN2147

So I think that's just a general acknowledgement that it's variable?‑‑‑Yes, there's - there is variability.

PN2148

Then if we go to page 85 in terms of "Shift of pharmacists' roles and responsibilities". Now you recall I asked you questions about what happened in 1998?‑‑‑This is the first person has had - - -

PN2149

This is the first guy, yes. So the first participant identified has been there 47 years of practice so obviously he'd been there in 1998. This is what you were referring to earlier, I gather, Professor Krass?‑‑‑Mm‑hm.

PN2150

VICE PRESIDENT HATCHER: So where are we now, Mr Seck?

PN2151

MR SECK: Sorry, page 85, Vice President.

PN2152

THE WITNESS: Page 85.

***�� INES KRASS�� XXN MR SECK

PN2153

MR SECK: Under the heading "Shift in pharmacists' roles and their responsibilities".

PN2154

VICE PRESIDENT HATCHER: Yes.

PN2155

MR SECK: The first thing is just going halfway down the page it says:

PN2156

In recent years there was seen to be an increased acknowledgement of the role of pharmacists.

PN2157

That seems more an acknowledgement in terms of perception. Do you agree that's what was being said there, Professor Krass?‑‑‑Yes, it is a perception that's being referred to.

PN2158

Yes.

PN2159

VICE PRESIDENT HATCHER: So, whose perception?‑‑‑The pharmacist's perception of how others perceive the role of pharmacists. But I guess that could be informed by many things by the fact that there are now recognised acknowledged services that are remunerated by the government, so that reflects recognition if you will.

PN2160

MR SECK: And there's also a suggestion at the bottom of page 85:

PN2161

There are certain responsibilities and tasks which pharmacists used to provide but now that's being passed on to other employees.

PN2162

Do you see that?‑‑‑Other technicians, yes.

PN2163

Other technicians. Was there any evidence in the interviewees' notes as to the kind of services which - - -?‑‑‑That would be dispensing.

PN2164

Dispensing?‑‑‑That would be the mechanics of dispensing.

PN2165

So that was revealed in the interviewees - - -?‑‑‑Yes.

***�� INES KRASS�� XXN MR SECK

PN2166

Okay, now if we go to page 87, at the bottom of the page you'll see it talks about "positive changes to the practice of the profession"?‑‑‑Yes.

PN2167

And would this be a fair summary of the positive aspects of the 6CPA initiatives; that it's the formalisation of services and the provision of or the requirement for formal documentation which arises, as opposed to the fact that these are completely new services? It's now that it's being done in a much more structured and organised way?‑‑‑I don't agree with that. I think that the process of formalising the services has made them recognised and delivered in a much more consistent way. So it's - we're talking about, you know, a difference in quality and I don't think I would - I won't use that word, you don't like it. But the structure that's underpinning these services now is I guess enforcing a certain quality and I think also encouraging more pharmacists to actually get on board to deliver these. I think the extent of provision has also increased. I wouldn't say that - yes, I'll leave it at that.

PN2168

When you say the extent, I think what's being said there is not really extended, it talks about formalisation?‑‑‑Well, he's talking about his own experience.

PN2169

Yes?‑‑‑There's one, you know, person but if you look across the board, you know, you can surmise that - and you look at what's been taken up by pharmacists particularly in relation to CPS, remunerated CPS, we can see that that - if you look at the trend over time it's been taken up by increasing numbers of pharmacists.

PN2170

Now go to then page 89, Professor Krass, which is 3.15 of the report. There's a perception of work value?‑‑‑Mm‑hm.

PN2171

So I think you acknowledged beforehand this is a perception of work value by the pharmacists, is that right, as opposed to the community? Yes?‑‑‑I think it's the perception of the pharmacists of the value of their work to the community.

PN2172

Right, but it's not - okay, right. And if you go to page 90, Professor Krass?‑‑‑Mm‑hm.

PN2173

The value seems to be or the perception of value seems to be that it's undervalued by patients. Do you see that halfway down?‑‑‑Yes. Yes.

PN2174

It says:

***�� INES KRASS�� XXN MR SECK

PN2175

Another participant felt the efforts of community pharmacists were not valued by patients.

PN2176

?‑‑‑Yes. Yes, yes.

PN2177

And then going down to the bottom of the page it says:

PN2178

Pharmacists were also responsible for undervaluing the profession.

PN2179

?‑‑‑Yes, I think he's referring to the discount model.

PN2180

Okay, I understand. Now if you go to page 91 onwards there's a suggestion by at least one or more of the pharmacists that the undervaluation is by the employed pharmacists themselves because they tend to sell themselves short in their negotiations with the pharmacy owners?‑‑‑Probably in some instances, but it's a matter of - are you looking - what are you looking at here?

PN2181

I'm sorry, I'm looking at about halfway down the page?‑‑‑Yes.

PN2182

Where it says:

PN2183

Of particular interest was one participant's description of an initial undervaluing of their own work as a pharmacist which was then highlighted by their employer during wage negotiations.

PN2184

And there's a quote there where his employer - or his or her employer - - -?‑‑‑He's a lucky pharmacist. I think that's not - that's the exception rather than the rule.

PN2185

When you say it's the exception, do you derive that from - - -?‑‑‑Yes.

PN2186

- - - other people?‑‑‑From other - that's right, yes.

PN2187

So this is noted here?‑‑‑Yes.

PN2188

And there's another one. Anyway, I'll come back to that. If you go to "Remuneration" which starts at 3.17?‑‑‑3.17. We're getting close to the end now.

***�� INES KRASS�� XXN MR SECK

PN2189

We are getting close to the end so, hopefully, we'll be there shortly. So the first part says:

PN2190

Remuneration at the pharmacy level.

PN2191

That's talking about the pharmacy owners not receiving adequate income from the government and consumers. That's right?‑‑‑Yes.

PN2192

But what we're more interested in is remuneration at the pharmacist's level?‑‑‑At the pharmacist level, yes.

PN2193

Which is at page 96?‑‑‑Yes.

PN2194

And I think it would be fair to say based on your report there's a mix of views as to the perceptions of remuneration which you say in the first sentence, "Mixed perceptions"?‑‑‑Yes.

PN2195

And there were both views amongst pharmacists that they were not getting paid enough?‑‑‑That's right.

PN2196

And some who said they were getting paid enough because it suited their circumstances?‑‑‑I don't think anyone said they were being paid enough.

PN2197

Okay, well - - -?‑‑‑I mean most of them were saying that they were not being paid enough.

PN2198

When you say "most"?‑‑‑Yes.

PN2199

I'm just going through the report here?‑‑‑Yes, okay.

PN2200

So you can tell me - but the numbers aren't here so I - if you go to - - -?‑‑‑Yes.

PN2201

If you go to for example page 98, because I acknowledge there are mixed views on this?‑‑‑Yes.

PN2202

About halfway down - about at the top of the page, page 98, it says:

***�� INES KRASS�� XXN MR SECK

PN2203

Another participant raised the notion that the incentive for undertaking additional training should be to add value to one's own skill set which would then in turn increase bargaining power when it came to wage levels. No one likes talking about money. It's something people don't enjoy but if you -

PN2204

et cetera:

PN2205

You don't have a lot to bargain with but if you're prepared to upskill, you commit to additional training, you add value to what you can offer a business. So we're talking about a community pharmacy setting and I think there is a lot of opportunity for early career pharmacists and pharmacists really to invest in themselves and seek investment of others to grow their skill set and have a higher negotiating power.

PN2206

Do you see that?‑‑‑Yes, I see that. I think that's one point of view.

PN2207

And there's another point of view below that?‑‑‑Yes, well there's the next one.

PN2208

Yes it says "Many factors"?‑‑‑Yes.

PN2209

And they say:

PN2210

However in contrast, others negotiated their hourly rates with their employer tailored for their circumstances or perceived expertise and value that they could offer the business.

PN2211

Do you see that?‑‑‑Yes.

PN2212

And there's a quote. So I think you say that would be one exception but in fact there are quite a number of participants who record their views here - I'm not going to read them all out to you - who seem to suggest that the value which you assign in terms of their remuneration is a function of their own desire to improve their skill set and improve their bargaining. Would you agree?‑‑‑No, I don't think so.

PN2213

Well, one person said that?‑‑‑One person said that.

PN2214

And another person says - - -?‑‑‑Yes.

***�� INES KRASS�� XXN MR SECK

PN2215

- - - it's about tailoring their particular circumstances to demonstrate what they can offer the business. That's what another person says?‑‑‑Yes, and then if you look at some of the negative - - -

PN2216

No, and I accepted that?‑‑‑Yes.

PN2217

But what I'm putting to you is that there's a mix of views?‑‑‑Well, there is. There is a mix, yes.

PN2218

Now if we go to the discussion and page 102 - well, one thing you recognise as a limitation is recall bias. Just so I understand and the Commission understands, what is recall bias?‑‑‑Recall bias is basically that you can't remember exactly what happened.

PN2219

And of course if you're remembering back to services you may have provided in the past and try and compare it to the future there might be recall bias that you may not have provided it, or you in fact provided it, which may not necessarily reflect the true - - -?‑‑‑Yes.

PN2220

The reality?‑‑‑You may not - I mean I think the - basically you may remember - you might - you would not remember the details. You would remember if you provided some type of service, but whether you provided it on a regular basis, when you began to provide it, that's unlikely that you could remember that. But if you were - you wouldn't be able to sort of locate it in time but you should be able to remember if - you know, when some - I guess people can remember things of a - seminal events when there's a change, when there's a specific change, that people can remember that. But they may not remember exactly when that change took place. I accept that and that's why we - you know, that's why it's written there as a limitation.

PN2221

And another limitation I think which you identify is that - and this is down the page at 102?‑‑‑Yes.

PN2222

Is the report focuses on formalised services but not necessarily routine practice. Would you accept that?‑‑‑Not just formalised services. It covers the scope of services. We don't - we weren't able to determine the frequency of delivery of these services but we were trying to identify the scope of practice. I think that's what that's referring to.

PN2223

Okay, now if we go to page 108 in the first paragraph of the last sentence you say:

***�� INES KRASS�� XXN MR SECK

PN2224

Evidently on the whole as wage levels have not purportedly increased alongside the increased provision of CPS by pharmacists over the years this has contributed to increased work related responsibilities for community pharmacists with the same financial incentive received.

PN2225

Now when you said "Evidently" I just want to be clear as to the evidence you were relying upon there?‑‑‑On the accounts of the interviewees.

PN2226

Right, so the accounts - - -?‑‑‑And others - well, other known sources. I mean we've actually - so there's a citation there to Hermansyah et al. We did - so that's a study that was done by my PhD student and he interviewed another - he interviewed I think 30 key informants also using a maximum variation sampling approach.

PN2227

I understand?‑‑‑Okay? So it's - - -

PN2228

So what - - -?‑‑‑-The evidence comes from several sources.

PN2229

Right, but this is not evidently based on the interviewees' evidence, it's based on Hermansyah's report?‑‑‑Yes.

PN2230

Okay, and if we now move to the conclusions, Professor Krass?‑‑‑Yes.

PN2231

I think your broad conclusion is set out in the first sentence but I think you agree that the incidence is higher for CPA funded programs?‑‑‑Yes, absolutely.

PN2232

As opposed to non-CPA funded programs?‑‑‑Yes, that's correct.

PN2233

Then you say halfway down the page:

PN2234

Over all it was reported there has been a prominent shift where professional services become the status quo of the profession. This change indicates there has also been a likely shift in the work value of community pharmacists.

PN2235

I just want to explore that with you. You say it has become the status quo, so when you say it has become the status quo you're referring to specific professional services aren't you?‑‑‑Yes.

***�� INES KRASS�� XXN MR SECK

PN2236

And the ones which have become the status quo are the ones which have - - -?‑‑‑The CPA, yes.

PN2237

The CPA ones?‑‑‑Yes. Plus some others.

PN2238

Plus?‑‑‑I mean, you know, blood pressure.

PN2239

Blood pressure?‑‑‑Blood glucose.

PN2240

Glucose. I think those are the other two where the majority provide - - -?‑‑‑Yes well - and flu vaccinations are becoming increasingly prevalent now as well and that will extend out to other vaccination programs too.

PN2241

Right?‑‑‑So it's not just flu vaccinations.

PN2242

And that status quo would only be based if the funding continued for the 6CPA program?‑‑‑Well, I can't speculate.

PN2243

Right. No further questions.

RE-EXAMINATION BY MR IRVING�� [1.17 PM]

PN2244

MR IRVING: Just one question.

PN2245

It's about HMRs. You gave evidence before that some pharmacists might be accredited but they might not exercise. Now do you know the extent to which pharmacists do get accredited but don't end up conducting at all?‑‑‑I can't put any numbers on it. I think it would be - it would probably be reasonably low because they have to pay a lot to actually become accredited. It's quite a process and a costly process, so I think that - but I do know of cases. I can't give you the exact statistics but I know of - from personal information that there are pharmacists who have actually undertaken the accreditation, haven't been able - in the hope of actually being able to get HMR work but haven't been able to and then have not renewed. Because yes, they have to - it's not just getting the first accreditation. They have to - that has to be renewed over time.

PN2246

And those who haven't been able to practice it?‑‑‑Yes.

***�� INES KRASS�� RXN MR IRVING

PN2247

Don't follow - renew it?‑‑‑Precisely, yes.

PN2248

Yes, okay.

PN2249

I have no further questions.

PN2250

VICE PRESIDENT HATCHER: All right, thank you for your evidence, Professor Krass, you're excused and you're free to go?‑‑‑Thank you.

<THE WITNESS WITHDREW�� [1.19 PM]

PN2251

VICE PRESIDENT HATCHER: We will now adjourn for lunch.

LUNCHEON ADJOURNMENT�� [1.19 PM]

RESUMED�� [2.09 PM]

PN2252

MR IRVING: I apologise for the delay, your Honours.

PN2253

VICE PRESIDENT HATCHER: That's all right.

PN2254

MR IRVING: Could I just clarify a couple of things before Mr Crowther is sworn?

PN2255

VICE PRESIDENT HATCHER: Yes.

PN2256

MR IRVING: Mr Crowther has given two statements which are found in volume 3 and annexed to his first statement which is behind tab 3.1 are some 21 annexures which consist of the annual remuneration reviews which are reports that are created by the applicant. So it's just a historical series.

PN2257

VICE PRESIDENT HATCHER: Yes.

PN2258

MR IRVING: The final document is a document which sets out the remuneration survey and the questions that were asked. The second statement, the reply statement which is behind 3.2, annexes two documents which is a survey on the graduate outcomes of the QILT survey on graduate outcomes for remuneration and some extracts from data from the ABS.

***�� INES KRASS�� RXN MR IRVING

PN2259

VICE PRESIDENT HATCHER: Just hold on a second.

PN2260

MR IRVING: In the volumes that have been handed up - - -

PN2261

VICE PRESIDENT HATCHER: I'll just - we've got our own set, Mr Irving, so.

PN2262

MR IRVING: Thanks.

PN2263

VICE PRESIDENT HATCHER: All right, can we swear in the witness then?

PN2264

MR IRVING: Yes, I just wanted to clarify a couple of things.

PN2265

VICE PRESIDENT HATCHER: I'm sorry, Mr Irving, yes.

PN2266

MR IRVING: AC21 is the principal document on which reference is going to be made. It's the most recent remuneration report.

PN2267

VICE PRESIDENT HATCHER: Yes.

PN2268

MR IRVING: The report does a couple of things. The first is it collects together the survey data which has been collected by Professionals Australia and Mr Crowther has been involved in collecting the data, and then it feeds it through a number of matrices, percentage of women, percentage of - you know, how many at this rate, how many at that rate. But then it goes on and makes a series of comments on the data; the commentary on the data of an industrial relations nature, things like - I'll paraphrase, "These people are grossly underpaid and justice needs to be done". We're calling Mr Crowther for the purpose of proving the data which was collected and the accuracy of the information contained in the data, not for the accuracy of the industrial relations commentary.

PN2269

VICE PRESIDENT HATCHER: So where is that in the report?

PN2270

MR IRVING: So for example on page 4 halfway down the page there is a statement:

PN2271

Pharmacists' jobs have increased in responsibility and complexity in recent years to include routinely providing vaccinations -

PN2272

blah, blah, blah.

PN2273

VICE PRESIDENT HATCHER: Yes, all right.

PN2274

MR IRVING: They're the sorts of - well, Mr Crowther's evidence that we're going to rely upon is strictly limited to the wages and remuneration data rather than those additional comments. It might assist in narrowing the cross‑examination somewhat.

PN2275

VICE PRESIDENT HATCHER: Yes, all right.

PN2276

MR IRVING: On that basis, if the Commission pleases, I'll call Mr Crowther.

PN2277

VICE PRESIDENT HATCHER: All right.

PN2278

THE ASSOCIATE: Mr Crowther, could you please state your full name and address?

PN2279

MR A CROWTHER: Alex Crowther - I guess the full name. Alex John Crowther. My address is (address supplied). There's a small typo. I put in unit (number supplied), not unit (number supplied). I had recently moved.

PN2280

THE ASSOCIATE: Thank you. I will now read out the affirmation.

<ALEX JOHN CROWTHER, AFFIRMED�� [2.13 PM]

EXAMINATION-IN-CHIEF BY MR IRVING�� [2.13 PM]

PN2281

MR IRVING: Mr Crowther, you say there's a typographical error in one of your statements. Which statement is that, the first or the second statement?‑‑‑It's the first statement. The first line of text where I say "I, Alex Crowther of" (address supplied). It should have read "I, Alex Crowther of" (address supplied).

PN2282

All right, other than that are the contents of the first statement you provided, are the contents true and correct?‑‑‑To the best of my knowledge, yes.

PN2283

Yes, I tender that.

***�� ALEX JOHN CROWTHER�� XN MR IRVING

PN2284

VICE PRESIDENT HATCHER: Does that have a date on it, Mr Irving?

PN2285

THE WITNESS: So the report's dated - I mean this statement is dated the 13th of December last year.

PN2286

VICE PRESIDENT HATCHER: Sorry, what was that, Mr Irving?

PN2287

MR IRVING: Sorry, 13 December 2017.

PN2288

VICE PRESIDENT HATCHER: 13 December.

PN2289

MR IRVING: On page 10.

PN2290

VICE PRESIDENT HATCHER: All right, so the statement of Alex Crowther dated 13 December 2017 will be marked exhibit 17.

EXHIBIT #17 STATEMENT OF ALEX CROWTHER DATED 13/12/2017

PN2291

THE WITNESS: December '17.

PN2292

MR IRVING: And your second statement titled "Reply Statement" which is dated 1 May 2018, are the contents of that true and correct?‑‑‑Yes, as far as I know.

PN2293

I tender that statement.

PN2294

VICE PRESIDENT HATCHER: Yes, so the reply statement of Alex Crowther dated 1 May 2018 will be marked exhibit 18.

EXHIBIT #18 REPLY STATEMENT OF ALEX CROWTHER DATED 01/05/2018

PN2295

MR IRVING: Thank you. I have no questions of this witness.

PN2296

VICE PRESIDENT HATCHER: All right.

PN2297

Mr Seck?

***�� ALEX JOHN CROWTHER�� XN MR IRVING

CROSS-EXAMINATION BY MR SECK�� [2.15 PM]

PN2298

MR SECK: Thank you.

PN2299

VICE PRESIDENT HATCHER: Mr Crowther, if you have any difficulty hearing the questions can you please tell us so we can make the necessary adjustments?‑‑‑Will do.

PN2300

MR SECK: Mr Crowther, my name's Michael Seck and I am the counsel for the - - -

PN2301

VICE PRESIDENT HATCHER: Can you pull up that microphone, Mr Seck?

PN2302

MR SECK: My name is Michael Seck, Mr Crowther. I am the counsel for the Pharmacy Guild of Australia. I'm just going to ask you just some short questions about both your statements. So do you have those statements in front of you at the moment?‑‑‑I actually seem to have very quickly misplaced the reply statement when I pulled everything out of my bag. I had it a moment ago. If it's okay I can get up quickly, go to my bag, which it's probably just sitting in there where I grabbed - - -

PN2303

VICE PRESIDENT HATCHER: Yes, please do that, Mr Crowther.

PN2304

MR SECK: Please.

PN2305

THE WITNESS: I do have it.

PN2306

VICE PRESIDENT HATCHER: You have it?‑‑‑Yes.

PN2307

Yes, all right.

PN2308

Mr Seck?

PN2309

MR SECK: Thank you, your Honour.

PN2310

Mr Crowther, just go to exhibit 17 which is your first statement.

***�� ALEX JOHN CROWTHER�� XXN MR SECK

PN2311

VICE PRESIDENT HATCHER: And Mr Crowther, can you point that microphone straight in front of you? Yes, thank you.

PN2312

THE WITNESS: Is that better?

PN2313

VICE PRESIDENT HATCHER: Yes it is.

PN2314

MR SECK: Go to page 4, paragraph 11?‑‑‑Mm‑hm.

PN2315

Now at paragraph 8 you talk about data being collected in relation to a whole series of issues. Do you see that?‑‑‑Yes.

PN2316

And do you know if data is collected or if it's contained in any of these reports about the number of employees who get paid award rates of pay as opposed to market rates of pay?‑‑‑We - when we ask people to tell us what their hourly rate is we don't explicitly look for whether or not someone is on the award rate when doing the analysis. So although the information is there in the dataset that is collected, if we were to go through and, you know, calculate the percentage of people who are on the award rate at that time, the analysis has not been done.

PN2317

Now put aside your first statement and go to your second statement?‑‑‑Okay.

PN2318

The reply statement, exhibit 18. Go to paragraph 2?‑‑‑Mm‑hm.

PN2319

Now you talk about pharmacy graduates compared to other graduates, Mr Crowther. I just want to understand when you refer to pharmacy graduates, you're not including pharmacy interns are you?‑‑‑I am including pharmacy interns.

PN2320

All right. So I understand, a pharmacy intern is someone who has graduated but is doing the intern year after graduation?‑‑‑Yes, a intern year after graduation.

PN2321

Okay, and if you go to paragraph 4?‑‑‑Mm‑hm.

***�� ALEX JOHN CROWTHER�� XXN MR SECK

PN2322

When you say - you talk about "pharmacists in their earlier stages career" this is in the Census data, and you talk about this is - so do you know if the Census data is looking at a particular period of time for pharmacists?‑‑‑So the - I think the second annex, AC24, which is the spreadsheet of data taken from the ABS shows on - well, I used an age range. In fact paragraph 4 states that. So the way that I selected out data that would be indicative of an early stage of career using ABS data was by looking at individuals that are - well, data that covers people in the 20 to 24 year old age bracket, which at the time was the best proxy I could find in the Census data to indicate early career.

PN2323

When was the comparison in paragraph 2 of graduate salaries - that's based on actual rate of pay as opposed to the award rate of pay as I understand it. Am I correct?‑‑‑Yes, the QILT survey, they go to graduates and they ask them what their commencing salary was when they first went into the workplace. The figures that are reported in that survey are those commencing salaries.

PN2324

No further questions.

PN2325

VICE PRESIDENT HATCHER: Any re‑examination?

RE-EXAMINATION BY MR IRVING�� [2.21 PM]

PN2326

MR IRVING: Yes.

PN2327

You were asked some questions about whether or not employees were paid at the award rate. Could I take you to page 9 of AC21?‑‑‑Yes.

PN2328

Now it - - -

PN2329

VICE PRESIDENT HATCHER: So what page was that?

PN2330

MR IRVING: Page 9.

PN2331

VICE PRESIDENT HATCHER: Thank you.

PN2332

MR IRVING: Now it doesn't in fact state what the award rate is for pharmacy intern and pharmacist et cetera, but could you just explain to the Commission what "lower decile" means in that context?‑‑‑I just want to confirm we're looking at page 9 of?

***�� ALEX JOHN CROWTHER�� RXN MR IRVING

PN2333

AC21, attachment AC21, the most recent remuneration report?‑‑‑Of the latest report, okay, sure. So lower decile is the measure of the percentage of people who fall below a certain number. So in this case if we looked at let's say pharmacy interns, the figure in graph 3.5, and we see here a lower decile figure of $22 per hour. That means that 10 per cent of survey respondents that self‑identified as pharmacy interns reported earning an hourly rate of $22 or less.

PN2334

And the lower quartile, is that similar for the lowest quarter?‑‑‑Yes, so for 20 per - 25 per cent rather than for 10 per cent.

PN2335

And the upper quartile and upper decile are at the other end of the scale?‑‑‑Yes, essentially. Percentiles have a little quirk in that say the upper decile is technically the 90 per cent of people who fall below. But, yes.

PN2336

And the median is?‑‑‑The median is the midpoint in the data that was collected. So you order the data and then you look at which of the entries was right in the middle.

PN2337

So if there's 324 it's what is paid to the 167 second person sort of thing in that sort of range?‑‑‑Essentially yes.

PN2338

Okay, and the mean is the average is it?‑‑‑Yes, so the mean is you take every reported figure, add them together, divide them by the number of figures we had.

PN2339

So we would know from that - whatever the award rate is - that we would know that if N equals 324 then the median, that half of the people are paid less than $22.48 an hour and half of them are paid more than $22.48 an hour?‑‑‑Yes, if the N was 324 for that category. Because for example in this case we're looking at the row for pharmacy intern, the N for pharmacy intern is 17. So in this case we could say that 50 per cent of people - or 50 per cent of respondents that are pharmacy interns are out of that 17 reported hourly earnings of $22.48 or less.

PN2340

VICE PRESIDENT HATCHER: Are the median and the upper quartile the same figure?‑‑‑No, the median - in this case it looks like it is. So there must have been quite a number of people who were paid on exactly that figure.

PN2341

Okay.

PN2342

MR IRVING: It's a few cents off the award.

PN2343

VICE PRESIDENT HATCHER: I see.

***�� ALEX JOHN CROWTHER�� RXN MR IRVING

PN2344

MR IRVING: I have no further questions.

PN2345

VICE PRESIDENT HATCHER: All right, thank you for your evidence, Mr Crowther. You're excused and you're free to go?‑‑‑Thank you.

<THE WITNESS WITHDREW�� [2.24 PM]

PN2346

MR IRVING: Finally, your Honours, we wish to tender the documents which I referred to in the opening which are listed in the opening folder in those various 19 tabs. There is as I understand it no objection to the tender of those documents as being what they state on their face to be.

PN2347

VICE PRESIDENT HATCHER: All right. Is it convenient simply to mark that as the APESMA document bundle?

PN2348

MR SECK: Yes.

PN2349

VICE PRESIDENT HATCHER: All right. So the APESMA document bundle will be marked exhibit 19.

EXHIBIT #19 APESMA DOCUMENT BUNDLE

PN2350

MR IRVING: There is one final document that we wish to rely upon which is the "Early Career Pharmacist White Paper" which wasn't in the bundle, but I understand there's no objection to that either.

PN2351

VICE PRESIDENT HATCHER: All right. So the document titled "Early Career Pharmacist White Paper 2017" will be marked exhibit 20.

EXHIBIT #20 DOCUMENT TITLED "EARLY CAREER PHARMACIST WHITE PAPER 2017"

PN2352

MR IRVING: There are two further things. The first is you asked us to do further homework about the registry data to see whether or not it's done. I don't have that document to tender but we shall do tomorrow morning.

PN2353

VICE PRESIDENT HATCHER: Right.

PN2354

MR IRVING: The second is to produce a table setting out the correct or the claimed rates, and I don't have that document either but we shall do so tomorrow morning. Subject to that, that is the case for the applicant.

PN2355

VICE PRESIDENT HATCHER: Thank you. Mr Seck?

PN2356

MR SECK: May it please your Honour. I don't propose to open. I think given the time and given that we've put on written submissions we can get stuck into it. I therefore call our first witness, Mr Angelo Pricolo. Can I enquire that your Honours have both the unredacted version and the redacted version?

PN2357

VICE PRESIDENT HATCHER: Yes, so we have the unredacted version.

PN2358

MR SECK: Hopefully there should have been an unredacted version which was also filed, which was sent through.

PN2359

VICE PRESIDENT HATCHER: Do we need the redacted version?

PN2360

MS WELLARD: No.

PN2361

MR SECK: No.

PN2362

VICE PRESIDENT HATCHER: We have the unredacted version.

PN2363

MR SECK: All right.

PN2364

THE ASSOCIATE: Could you please state your full name and address?

PN2365

MR A PRICOLO: Angelo Pricolo (address supplied).

<ANGELO PRICOLO, SWORN�� [2.29 PM]

EXAMINATION-IN-CHIEF BY MR SECK�� [2.29 PM]

PN2366

VICE PRESIDENT HATCHER: Mr Seck?

PN2367

MR SECK: Thank you, your Honour.

PN2368

Please state your full name for the record?‑‑‑Angelo Pricolo.

***�� ANGELO PRICOLO�� XN MR SECK

PN2369

And what is your current work address?‑‑‑32 Sydney Road, Brunswick.

PN2370

What is your current occupation?‑‑‑Pharmacist.

PN2371

Mr Pricolo, you have prepared a witness statement in these proceedings. Is that so?‑‑‑Correct, yes.

PN2372

That witness statement was signed on 18 April 2018, yes?‑‑‑Correct.

PN2373

Do you have a copy of that statement with you in the witness statement?‑‑‑I do. Yes, thank you.

PN2374

Have you read that statement recently?‑‑‑I just had a quick glance at it outside.

PN2375

And have you read it prior to - - -?‑‑‑Of course.

PN2376

Yes, and having read the statement do you wish to make any changes to the statement?‑‑‑No, I'm happy with what I wrote.

PN2377

Are the contents of the statement true and correct to the best of your knowledge and belief?‑‑‑Yes.

PN2378

I tender the statement.

PN2379

VICE PRESIDENT HATCHER: Yes, so the affidavit.

PN2380

MR SECK: Affidavit.

PN2381

VICE PRESIDENT HATCHER: Of Angelo Pricolo sworn on 18 April 2018 will be marked exhibit 21.

EXHIBIT #21 AFFIDAVIT OF ANGELO PRICOLO SWORN 18/04/2018

PN2382

MR SECK: Given it's an affidavit perhaps I should formally read it then if that's the case, your Honour. I have no further questions.

***�� ANGELO PRICOLO�� XN MR SECK

PN2383

VICE PRESIDENT HATCHER: Mr Irving?

CROSS-EXAMINATION BY MR IRVING�� [2.30 PM]

PN2384

MR IRVING: Mr Pricolo, you're a member of the Pharmacy Guild?‑‑‑Yes I am.

PN2385

And you're an office holder in the Pharmacy Guild?‑‑‑I am, yes.

PN2386

And what office do you hold?‑‑‑I am currently a - on the branch committee in Victoria.

PN2387

And what office on the branch committee do you hold? Are you just a branch committee member?‑‑‑I - correct.

PN2388

Have you previously held other offices in the branch committee?‑‑‑Yes, I was vice president in Victoria.

PN2389

You were vice president for how long?‑‑‑A term I suppose, so three years.

PN2390

Okay, and that term ended when?‑‑‑Ended last year.

PN2391

And so from 2014 to 2017 approximately you were vice president?‑‑‑Yes, correct.

PN2392

Prior to being vice president were you a member of the Pharmacy Guild committee?‑‑‑I was a part of the branch committee prior to that as well, yes.

PN2393

And for how long have you been a member of the branch committee?‑‑‑The previous three years to that.

PN2394

Okay, so approximately 2011 to 2014?‑‑‑That sounds right, yes.

PN2395

Okay, and prior to being a member of the branch committee for that term were you a member of the Pharmacy Guild governing structure?‑‑‑I wasn't a part of the structure. I was a member of the guild but I wasn't involved at branch committee level, no.

***�� ANGELO PRICOLO�� XXN MR IRVING

PN2396

So you've just been an ordinary member - - -?‑‑‑Correct.

PN2397

- - - up until 2011?‑‑‑Correct.

PN2398

The guild is an organisation registered under the Fair Work Registered Organisations Act?‑‑‑Mm‑hm.

PN2399

And it's an employer body?‑‑‑(No audible reply)

PN2400

Sorry, you're going to have to say yes or no?‑‑‑Sorry, yes. Yes.

PN2401

And it represents community pharmacists across Australia?‑‑‑It represents community pharmacist owners across Australia.

PN2402

So community pharmacist owners, yes. Thank you, and there are about 5,500 community pharmacists?‑‑‑I think that's about right.

PN2403

Sorry, community pharmacy businesses?‑‑‑Correct. Yes.

PN2404

VICE PRESIDENT HATCHER: So what was that number again?

PN2405

MR IRVING: About 5,500.

PN2406

And a portion of them will be members of the Pharmacy Guild?‑‑‑Correct.

PN2407

And do you know approximately what portion?‑‑‑Seventy-ish.

PN2408

Okay, so about 70 per cent of community pharmacy owners are members of the guild, yes?‑‑‑Correct.

PN2409

And the guild has a function in representing the interests of community pharmacy owners in various forums including in this case?‑‑‑Yes.

PN2410

And they advocate on behalf of community pharmacy owners by participating in government reviews?‑‑‑Yes.

***�� ANGELO PRICOLO�� XXN MR IRVING

PN2411

And during your time there, there has been various submissions made to government bodies about a range of issues affecting community pharmacy owners?‑‑‑I think the most recent was probably the King review.

PN2412

Okay, so the King review into remuneration?‑‑‑All sorts of things, yes.

PN2413

All sorts of things related to community pharmacy owners?‑‑‑Yes, that's right.

PN2414

And one of the functions of the PGA is to represent community pharmacy owners in the negotiation of community pharmacy agreements?‑‑‑Correct.

PN2415

And they are agreements which operate every five years or so, or have about a five year term and have been around for 20‑odd years at least?‑‑‑That's right. So we've just - we're currently in six, and seven is, yes, obviously the next one which is probably three years away, three and a half years away.

PN2416

The guild as well as that representative function also has an advocacy function, it also has an educative function for its members?‑‑‑Yes.

PN2417

And the guild is active in providing CPDs?‑‑‑Yes.

PN2418

And the guild is active in informing members of any changes in regulations which might affect their practice?‑‑‑Yes.

PN2419

And those changes in regulations will include things like changes in the competency standards?‑‑‑Yes, look - yes, although I suppose to a degree the PSA is also involved in that. So, yes, where that information comes from can vary a little bit.

PN2420

And so you're not the sole source of the information for your members about this?‑‑‑Correct.

PN2421

But one of the things that the PGA does is to engage in this educative function?‑‑‑Yes, definitely. Yes.

***�� ANGELO PRICOLO�� XXN MR IRVING

PN2422

And when there are reviews of documents like, you know, competency standards or professional standards and codes of ethics and that sort of thing, the PGA takes an active role in advocating on behalf of community pharmacy owners about what these standards and codes should look like?‑‑‑I think the PGA definitely has an input and it's probably a bit wider than just advocating for pharmacy owners. I think they have a vested interest in the profession as well.

PN2423

Yes, and their input includes making submissions to whatever body it is, the PSA or whomever who make those standards?‑‑‑Correct.

PN2424

And once a standard is made and changed there is an interest in - or one of the functions the PGA performs is to educate its members about what new or differences might have arisen as a result of these reviews?‑‑‑I think that's a reasonable statement.

PN2425

In the course of making submissions about what should be contained in these codes and guidelines and competency standards et cetera, the PGA seeks information from its members about what they consider to be appropriate standards or codes or guidelines?‑‑‑Yes.

PN2426

And it involves consultation with members?‑‑‑Yes.

PN2427

And it might involve surveying members?‑‑‑Yes I suppose it could.

PN2428

And there are various other consultative mechanisms that the PGA has adopted over time to gain information from its members about what should be contained in these codes, guidelines and standards?‑‑‑It communicates with its members, of course.

PN2429

And it seeks their views and input so that it can in turn influence the outcomes?‑‑‑I think so, yes.

PN2430

You refer in the course of your statement to a couple of documents, the award and MIMS. Other than that did you have reference to any specific documents in preparing this statement?‑‑‑No, I think it was largely formed based on my experience as a pharmacist over the years.

PN2431

You mentioned that you've got a Bachelor of Pharmacy which you got in 1986?‑‑‑Yes.

PN2432

And was that from a Victorian based university?‑‑‑So when I was an undergraduate that was the Victorian College of Pharmacy and it now is a part of Monash University.

***�� ANGELO PRICOLO�� XXN MR IRVING

PN2433

Okay, and they awarded Bachelor degrees back then?‑‑‑Correct.

PN2434

Have you got a Masters?‑‑‑No, I started one but I didn't finish it.

PN2435

So no Masters. No PhD?‑‑‑No.

PN2436

Have you published any research into changes in the work performed by pharmacists over the last 20-odd years?‑‑‑No.

PN2437

Have you jointly authored any articles with anyone about changes - - -?‑‑‑I've got one - not - no, sorry. Sorry for interrupting. Not about changes in workforce or - no.

PN2438

You haven't conducted any literature reviews of any studies into changes in the way that pharmacists have performed work over the course of the last 20 years?‑‑‑No.

PN2439

You don't annex any reports done by the PGA to your statement. That's right?‑‑‑Yes.

PN2440

And there are no reports about any changes in pharmacy practice over the last 20 years?‑‑‑No.

PN2441

No. None of the surveys that might have been conducted of any of the members about what changes have occurred over the last 20 years - - -?‑‑‑I didn't use those in preparing this statement, if that was your question. Yes.

PN2442

And to the extent any surveys or reports exist created by the PGA about such changes, you've decided not to make them part of the statement to the Commission?‑‑‑I didn't think they were necessary so, no, I didn't. Yes.

PN2443

Okay. You've said you didn't make specific reference to any documents in the preparation of this statement. I take it then that you did not track down any professional standards that existed 15, 20 years ago and compare it to the professional standards that now exist, in the course of preparing this statement?‑‑‑No, although I'm aware of the professional standards and I've quoted them in other areas of my working life. But no, I didn't specifically find them out and compare them for this paper, no.

***�� ANGELO PRICOLO�� XXN MR IRVING

PN2444

And similarly you didn't make reference to any of the codes of conduct that existed back in 1998 and those that currently exist now?‑‑‑No.

PN2445

And similarly you didn't make reference to any of the competency standards that previously existed and exist now?‑‑‑Correct.

PN2446

There are professional standards that are made by the PSA, yes?‑‑‑Yes.

PN2447

And they're endorsed by the PBA, the Pharmacy Board of Australia. Are you aware of that?‑‑‑That's correct, yes.

PN2448

Okay, and they set standards about how work is to be done by pharmacists, yes?‑‑‑Yes.

PN2449

Could I take you to a document which is in volume 2 of the annexures in front of you. Sorry, volume 2 and it's tab number 25.

PN2450

VICE PRESIDENT HATCHER: That is GM25 is it?

PN2451

MR IRVING: GM25.

PN2452

Do you have that in front of you?‑‑‑Yes.

PN2453

Excellent. Could I take you to page 3. I just want to ask you a few questions just about the nature of the standards. First - - -?‑‑‑Just - sorry that's the - Grant Kidachi's statement. Is that page 3?

PN2454

That's correct?‑‑‑Yes.

PN2455

And it's in the second paragraph. Mr Kidachi explains that:

PN2456

The latest version of PPS reflects the important role of pharmacists involving the health care sector. There is a renewed focus on patient-centred collaborative care.

***�� ANGELO PRICOLO�� XXN MR IRVING

PN2457

You'd agree that there is a renewed focus on patient‑centred collaborative care?‑‑‑A renewed focus? I'm not sure what he means by a renewed focus. I mean there's been a focus on patient‑centred collaborative care for a long time.

PN2458

Yes and:

PN2459

There are new standards that detail emerging professional activities such as vaccination and minor ailment services.

PN2460

They are emerging professional activities conducted by pharmacists. You'd agree with that?‑‑‑Yes.

PN2461

And if I could take you to page - - -

PN2462

VICE PRESIDENT HATCHER: So just before you move on, what are minor ailment services?‑‑‑I suppose that's - it depends on your definition but from my point of view as a pharmacist I suppose there are conditions when people would come in and seek advice from a pharmacist where they may or may not be sure whether they need to see a doctor, and they'll come in and see us and it's - I suppose it's a call made by the pharmacist as to whether the pharmacist thinks it's appropriate or within their scope to be able to look after the patient, or whether their recommendation is that they would refer and ask them to go and see a doctor. So in really broad terms without being specific about what one of those ailments could be, I suppose that's how I'd describe it.

PN2463

Thank you.

PN2464

MR IRVING: So would you agree with the following definition that:

PN2465

Minor ailment services are advice on medicines and treatments for minor ailments such as coughs, colds, headaches, skin disorders, diarrhoea, constipation, eye infections, amongst others.

PN2466

?‑‑‑Yes.

PN2467

VICE PRESIDENT HATCHER: So is that definition in the standard, Mr Irving?

PN2468

MR IRVING: That is the definition from Professor Krass' report, page 137.

***�� ANGELO PRICOLO�� XXN MR IRVING

PN2469

VICE PRESIDENT HATCHER: Thank you.

PN2470

MR IRVING: As numbered down the bottom.

PN2471

THE WITNESS: Yes, as I said I think there are various ways that you could describe them and that's certainly one of them.

PN2472

MR IRVING: Okay, if I could take you to page 8 of the statement - of the professional standards. There's a description there by the PSA, the opening sentence:

PN2473

Pharmacists in Australia are facing new and evolving challenges relating to an increasingly complex health care system.

PN2474

You'd agree with that?‑‑‑Yes.

PN2475

And in the next paragraph:

PN2476

The PSA's professional practice standards articulate the expected standards of professional behaviour of pharmacists in Australia.

PN2477

Do you agree with that?‑‑‑Yes.

PN2478

And part of the role of these professional standards is set out at the bottom of that first column where in the penultimate sentence it says:

PN2479

In its role of public protection the Board may refer to or use the PPS when considering complaints or notifications involving the conduct or behaviour of a pharmacist. Breaches of these standards may result in notification to the Board.

PN2480

?‑‑‑Yes.

PN2481

You understand that's the case?‑‑‑Yes.

***�� ANGELO PRICOLO�� XXN MR IRVING

PN2482

And as these standards change over time - I'll take a step back. There were previous iterations of the professional standards?‑‑‑I think so, yes.

PN2483

And as they changed over time what was required and expected of pharmacists similarly changed over time?‑‑‑I suppose the standard would be different from its previous version. Yes, it would be updated. I can't tell you specifically how they changed. I don't remember, but.

PN2484

And the best way to ascertain the extent to which they've changed would be just to look at the two documents side by side and figure out what the change is by reading it?‑‑‑In the document?

PN2485

Yes?‑‑‑I'm sure, yes.

PN2486

And the way in which the best way to measure the extent to which there has been changes in expected standards of pharmacists is to look at those two documents side by side?‑‑‑I think that's a good way of doing it, yes.

PN2487

VICE PRESIDENT HATCHER: So did you accept that those changes would be one of identifying changing work requirements expected of pharmacists?‑‑‑Yes I - in some instances, yes.

PN2488

MR IRVING: Well, in all instances - - -?‑‑‑It's a general kind of a statement so I'm not really sure what I'm agreeing to. But I think that the standards will vary and they will make an attempt to vary in line with the work that a pharmacist does.

PN2489

Yes and - okay, that's fine. And in dispensing prescriptions under the PBS, pharmacists must comply with the professional standards?‑‑‑I think that's a reasonable request, yes.

PN2490

And it's a requirement of the legislation is it not?‑‑‑Of the - to receive your remuneration from the PBS.

PN2491

Yes?‑‑‑Yes. Yes. Yes.

PN2492

Okay, so it's not just a change in expectation, it's a requirement to get the money to do it in the way which is now provided for in the professional standards?‑‑‑I think that's accurate, yes.

***�� ANGELO PRICOLO�� XXN MR IRVING

PN2493

If you look at halfway down page 3 there is a hierarchy of guidance and regulation of pharmacy practice.

PN2494

VICE PRESIDENT HATCHER: On page 8?

PN2495

MR IRVING: Sorry, on page 8 still.

PN2496

And there's a figure one, do you see that there?‑‑‑Mm‑hm.

PN2497

And it sets out this hierarchy. Are you familiar with that diagram? Have you seen that sort of diagram before?‑‑‑Yes. Yes.

PN2498

Okay, and the Pharmacy Board of Australia sets certain registration standards and codes and guidelines, yes?‑‑‑Yes.

PN2499

The Pharmacy Board of Australia came into existence in about 2008 or so. Is that right?‑‑‑That sounds reasonable.

PN2500

And the codes of ethics; there has been codes of ethics that were applicable in 1998 and there are a code of ethics applicable now?‑‑‑Mm‑hm.

PN2501

And there are competency standards which now exist and they're different to those that existed in 2001 et cetera?‑‑‑Yes.

PN2502

Okay, and we're dealing here with professional practice requirements set out in the practice standards. There are also quality standards which are contained in the QCCP. Is that right?‑‑‑Yes.

PN2503

And the QCCP is a program that all pharmacists - pharmacy owners must comply with to get access to PBS benefits. Is that correct?‑‑‑To get access to - I'm not a hundred per cent sure if it's to PBS. It certainly is to the extra moneys that are allocated in things like the 6CPA. But it probably is the PBS as well but I'm not a hundred per cent sure, sorry.

PN2504

The evidence is that the QCCP were created in around 2000 or so. Does that accord with your recollection?‑‑‑Yes, it sounds about right.

***�� ANGELO PRICOLO�� XXN MR IRVING

PN2505

And it sets out a series of requirements that must be met by pharmacy owners in a whole range of fields to gain access to some benefits. Yes?‑‑‑Yes.

PN2506

And does that look familiar?‑‑‑Yes it does.

PN2507

Okay, that's just the list of - that's the requirements. Is that it?‑‑‑It is, yes.

PN2508

So these are the QCCP requirements which were prepared after 2000 and they cover elements ranging from compliance with legal and professional obligations to information technology, a huge range of issues?‑‑‑Everything to, you know, what - how to lock the front door. I think everything is in there. It's very comprehensive.

PN2509

And there are random audits which are - sorry, there are audits that are conducted every two years concerning compliance with these standards?‑‑‑Yes.

PN2510

And there are also the possibility of random audits?‑‑‑I don't think we've had a random audit. I don't know that there's a facility for a random audit. I could be wrong, but I certainly haven't had one.

PN2511

Would it surprise you to learn that the PGA provides information to its members about QCCP which concerns the possibility of random audits and how to deal with them?‑‑‑Sorry, what was the question?

PN2512

Would it surprise you to know - well, I'll take a step back. I'll come back to that in a moment. Now the professional standards that you met in the course of your practice in 1995 complied with presumably the professional standards that - - -?‑‑‑1995?

PN2513

Sorry, 1997 did you say?‑‑‑87.

PN2514

87, okay. The professional standards that you met in 1987 were the professional standards that existed in 1987?‑‑‑Correct.

PN2515

And those that you complied with in 1998 were those that existed in '98?‑‑‑Correct.

PN2516

And those you complied with in 2017 or 18 were those which currently exist?‑‑‑I certainly try my best.

***�� ANGELO PRICOLO�� XXN MR IRVING

PN2517

And you have changed your practice to reflect the changes in the professional standards required of you?‑‑‑I - my practice has evolved over the years as a pharmacist and I always comply with the requirements. So yes.

PN2518

And you comply with the requirements in existence at the time?‑‑‑Correct.

PN2519

You weren't complying back in 1987 with the requirements that exist now?‑‑‑Well, in some cases I was because they haven't changed. But if things have changed then I've changed with it, because I want to stay registered as a pharmacist and conduct my business.

PN2520

All right, and you haven't done a comparison between the requirements that exist now with the requirements that existed back in 1998?‑‑‑No.

PN2521

There's a code of ethics that is made by the PSA?‑‑‑Yes.

PN2522

And it's endorsed by the PBA?‑‑‑Yes.

PN2523

And it applies to all practice as a pharmacist?‑‑‑Yes.

PN2524

And could I take you to tab number 28?‑‑‑The same folder?

PN2525

The same folder, GM28?‑‑‑Yes.

PN2526

And that's a copy of the current code of conduct. Could I take you to page 5. There's a description there of the purpose and the scope of the code and in the final sentence of the first paragraph it says:

PN2527

Ethical professional practice is central to PSA's vision of improving our nation's health through excellence in the practice of pharmacy.

PN2528

You would agree that ethical professional practice is central in the way they describe there?‑‑‑Absolutely.

PN2529

And that the code underpins the professional practice of all pharmacists in Australia?‑‑‑Yes.

***�� ANGELO PRICOLO�� XXN MR IRVING

PN2530

And if I take you to the next page on page 7, if you look halfway or two-thirds of the way down the page it's a paragraph starting with "In addition". Do you see that?‑‑‑Mm‑hm.

PN2531

So:

PN2532

In addition, compliance with the PSA's professional practice standards in this code is a requirement for pharmacists to be able to dispense and supply medicines on the PBS -

PN2533

Or:

PN2534

- on the Pharmaceutical Benefits Scheme.

PN2535

Yes?‑‑‑Yes.

PN2536

And it's a requirement to meet the code in the way in which the work is done by pharmacists, yes?‑‑‑Yes.

PN2537

And that requirement did not exist in 1998. Were you aware of that?‑‑‑No.

PN2538

Okay, and in 1998 there was a code of conduct. Were you aware of that?‑‑‑I assume there would have been but I'm not vividly aware. I don't think - I may not have read it at the time, but.

PN2539

And you haven't done a comparison as to - - -?‑‑‑No.

PN2540

- - - what the current code requires and what the old code requires?‑‑‑No.

PN2541

And that's a measure of the different ways in which work is done by pharmacists, isn't it?‑‑‑The code of conduct is a measure?

PN2542

The code of conduct is a requirement as to how the work is performed. Do you agree with that?‑‑‑Yes, a part of it. Yes.

***�� ANGELO PRICOLO�� XXN MR IRVING

PN2543

And one of the requirements - and to the extent that there has been a requirement in 1998 to perform it in accordance with this way, and there's a requirement in 2018 to perform it in a different way, one of the ways in which we can discover the extent to which work has changed is to compare the two documents. You'd agree with that?‑‑‑Well, as I said I haven't done that comparison. I'm just - I just don't think that there would be that big a difference in the way that the work is done as you're saying.

PN2544

I understand that?‑‑‑Yes.

PN2545

But you haven't looked, have you?‑‑‑No, I said I hadn't. No.

PN2546

If I take you to paragraph 10 - page 10, it sets out the seven principles of the code?‑‑‑Yes.

PN2547

Are you aware that the principle in paragraph 2 was not a principle of the code in 1998?‑‑‑No.

PN2548

Were you aware that the principle in the code in principle 3 was not a requirement in 1998?‑‑‑No.

PN2549

Were you aware that the principle in competency principle 1 was not a requirement in 1998?‑‑‑No.

PN2550

To the extent that pharmacists are performing in accordance with this lawful requirement, they're performing work in a different way now than they were previously?

PN2551

MR SECK: I object.

PN2552

MR IRVING: It's more in the nature of a submission, so I can move on.

PN2553

Could I take you to tab GM23. This is the national competency standard. Are you familiar at all with this document?‑‑‑Yes.

PN2554

Could I take you to page 7. You see in the second paragraph in page 7:

***�� ANGELO PRICOLO�� XXN MR IRVING

PN2555

Competency standards describe the skills, attitudes and other attributes including values and beliefs attained by an individual based on their knowledge and experience which together enable the individual to practice effectively as a pharmacist.

PN2556

You understand that's what competency standards do?‑‑‑Yes.

PN2557

And they describe those skills which are necessary to do the job effectively?‑‑‑Mm‑hm.

PN2558

And there were competency standards that preceded the current version. Were you aware of that?‑‑‑Yes.

PN2559

Could I take you to the next page, "Key Influences"? Under the heading "Key Influences" and under that heading there's a key statement about practice of pharmacy there. Yes?‑‑‑Yes.

PN2560

And you haven't looked at previous iterations of this document in the course of preparing your evidence, have you?‑‑‑Correct.

PN2561

Okay, and under that definition - well, in that definition it includes in the second paragraph:

PN2562

The practice of pharmacy includes the custody, preparation, dispensing and provision of medicine.

PN2563

Can you see that?‑‑‑Yes.

PN2564

And that is a core part of pharmacy that has existed for decades and decades and decades. You'd agree with that?‑‑‑Yes.

PN2565

And you'll see underneath there there's a reference to the National Medicines Policy?‑‑‑Mm‑hm.

PN2566

Are you familiar with the National Medicines Policy?‑‑‑I haven't read it recently, no.

PN2567

Did you read it when it was made?‑‑‑I don't remember. I may have.

***�� ANGELO PRICOLO�� XXN MR IRVING

PN2568

You're presumably familiar with the sixth version of the CPA?‑‑‑Mm‑hm.

PN2569

You haven't looked at and read the second and third versions of the CPA?‑‑‑No.

PN2570

Okay and - I can move on from that document. If I could take the witness to exhibit 20.

PN2571

VICE PRESIDENT HATCHER: Sorry, I've spilt some water here, Mr Irving.

PN2572

MR IRVING: Look, I've done it many times before.

PN2573

VICE PRESIDENT HATCHER: We'll battle on. I think we'll survive.

PN2574

MR IRVING: I'll stop because every word I think utters from my mouth is gold, so I wouldn't want you to miss a syllable.

PN2575

VICE PRESIDENT HATCHER: I'm all ears. Yes go on, Mr Irving.

PN2576

MR IRVING: Thank you.

PN2577

If I could take the witness to exhibit 21. I've got an additional copy here. Sorry, exhibit 20 which is the multi-coloured document handed up just after the folder this afternoon.

PN2578

VICE PRESIDENT HATCHER: It's a bit wet but (indistinct), yes.

PN2579

MR IRVING: Do we have an extra copy? We've got a dry copy here. That might help. Sorry, could I have the witness shown that document?

PN2580

VICE PRESIDENT HATCHER: Yes.

PN2581

MR IRVING: Sorry, for the witness.

PN2582

SPEAKER: For the witness.

***�� ANGELO PRICOLO�� XXN MR IRVING

PN2583

MR IRVING: This is a white paper concerning early career pharmacists done by the PSA. Could I take you to page 3 of the document. It's a statement by Dr Shane Jackson, the PSA national president. If I could take you to the second sentence. It says:

PN2584

The recommendations contained in this report are a high priority to the PSA to ensure a bright future for all pharmacists.

PN2585

Do you see that?‑‑‑Yes.

PN2586

The PGA wants a bright future for all pharmacists, doesn't it?‑‑‑Yes.

PN2587

Yes, and it says:

PN2588

The rationale highlighted for the recommendations contained in this white paper shows a considered approach by ECP -

PN2589

That's early career pharmacists:

PN2590

- that highlight that remuneration and the sustainability of the pharmacy industry is a high priority for them.

PN2591

The PGA wants a sustainable pharmacy industry doesn't it?‑‑‑Yes.

PN2592

If I take you through to the sixth page, about a third of the - halfway down the page at the paragraph starting "The Australian pharmacy sector":

PN2593

The Australian pharmacy sector is undergoing significant change as a result of the strong reform agenda from government at both federal and state/territory levels.

PN2594

You'd agree that's occurring?‑‑‑Yes.

PN2595

And on the next page the PSA convened - the description of the convening of a white paper advisory group. Were you personally a member of that advisory group?‑‑‑I'll say no, but what year was it?

***�� ANGELO PRICOLO�� XXN MR IRVING

PN2596

Last year?‑‑‑No I wasn't.

PN2597

Sorry, yes, last year. No?‑‑‑No.

PN2598

All right, could I take you to the recommendations, the key recommendations. The white paper has 10 key recommendations on page 8. Number 2 is:

PN2599

To negotiate to raise the pharmacy industry awards.

PN2600

The PSA, they're the professional body, yes?‑‑‑Yes.

PN2601

And they have done a white paper on early career pharmacists. Have you seen this before?‑‑‑No.

PN2602

And on the next page:

PN2603

During consultation for the white paper it became apparent that many early career pharmacists in Australia are dissatisfied with their careers.

PN2604

Has the PGA done any research about the dissatisfaction with their careers by early career pharmacists?

PN2605

MR SECK: I object. Relevance.

PN2606

VICE PRESIDENT HATCHER: Sorry, what was the objection?

PN2607

MR SECK: Relevance.

PN2608

VICE PRESIDENT HATCHER: I'll allow the question.

PN2609

MR IRVING: Has the PGA done any research on the dissatisfaction of early career pharmacists with their careers?‑‑‑I'm not sure. I don't think I've seen it but it doesn't mean they haven't.

PN2610

And it says here:

***�� ANGELO PRICOLO�� XXN MR IRVING

PN2611

During consultation it became apparent that many early career pharmacists became disillusioned with the sector more broadly.

PN2612

Are you aware of any research by the PGA about disillusionment by early career pharmacists with the sector?‑‑‑I'm not aware.

PN2613

And it says in the final sentence in that column:

PN2614

Inadequate remuneration was the single largest issue identified by early career pharmacists.

PN2615

The PGA is aware that inadequate remuneration is the single largest issue with early career pharmacists, isn't it?‑‑‑The PSA is, sorry?

PN2616

The PGA is aware of that?‑‑‑I don't know. It - I think it's definitely an issue for a lot of pharmacists but I don't know that they've specifically done a survey on it, no.

PN2617

You'd agree that dissatisfaction and disillusionment with the sector should be addressed? Do you agree with that?‑‑‑Yes, of course.

PN2618

And one of the best ways of addressing it is to rectify the inadequate remuneration that's paid. You'd agree with that?‑‑‑I think that people should be paid for the job that they do, yes.

PN2619

And at the moment the payment for the job that they do is considered so inadequate that employees in the sector are dissatisfied and disillusioned with their careers?‑‑‑Well, that's what these people that were questioned said, yes.

PN2620

If that's correct that's a dire state that should be rectified, shouldn't it?‑‑‑I think that there are a lot of measures of satisfaction and pay is definitely one of them, and from this survey it seems the people they asked were not happy with their pay, yes.

PN2621

And the PGA would support measures to improve remuneration so that that dissatisfaction and disillusionment is addressed. You'd agree with that?‑‑‑Well, I don't think anybody wants to underpay their staff, if that's what you're saying.

***�� ANGELO PRICOLO�� XXN MR IRVING

PN2622

No, we're talking about increasing the pay of their staff to address disillusionment?‑‑‑Well, I think that as a pharmacy owner one of the things I do to encourage my staff is sometimes to increase their pay, yes.

PN2623

And increasing the pay is one of the ways in which that disillusionment might be either nipped in the bud or - - -?‑‑‑I think it can help. I think taking them out for dinner occasionally and doing the things that a good boss does, and one of them is - included in that is paying your staff more, yes.

PN2624

And if you look at recommendation 2 on the next page it says:

PN2625

Both the 2015 and 2016 PSA member survey demonstrated that PSA members feel that inadequate remuneration is the biggest challenge facing the pharmacy profession. Similarly early career pharmacists identified the lack of appropriate remuneration as a major issue in the profession.

PN2626

You'd agree that is a major issue in the profession?‑‑‑I think that pay is always an issue for people in their work and there's no difference in pharmacy. Everybody wants to get paid more for what they do.

PN2627

This is not just everybody. This is an industry in which people, in which early career pharmacists are expressing high degrees of dissatisfaction. You understand that, don't you?‑‑‑Yes I do.

PN2628

Okay, so in fact in the next paragraph it says:

PN2629

Remuneration is unsurprisingly a key factor to early career pharmacists in determining job satisfaction with 70 per cent of ECPs rating it as either very important or extremely important in determining their level of job satisfaction.

PN2630

You'd agree that 70 per cent of the workforce identifying that as an important factor is a significant concern, yes?‑‑‑Yes it is, of course.

PN2631

It's important for this sector to be sustainable, you agree? You've previously agreed with that?‑‑‑I still do.

PN2632

And one of the ways in which this sector becomes sustainable is to retain its early career pharmacists?‑‑‑Yes.

***�� ANGELO PRICOLO�� XXN MR IRVING

PN2633

If the sector loses its young then it's not going to be sustainable into the future; its young workers, it's not going to be sustainable into the future?‑‑‑Well, I think that's a fair statement.

PN2634

And so the best way in which that can be done is to improve the rates of pharmacists at the early stages of their career. Do you agree with that?‑‑‑I think it would improve retention, yes.

PN2635

It is said that:

PN2636

More than 80 per cent of survey respondents indicated they believed that remuneration for early career pharmacists could be improved by re-negotiation of pharmacy industry award rates.

PN2637

The PGA supports an increase pharmacy industry award rates doesn't it?‑‑‑An increase?

PN2638

Yes?‑‑‑I don't - what document are you reading, sorry?

PN2639

Well, to address this problem that there is in the industry. Does the PGA support an increase in the pharmacy industry award rates?‑‑‑I don't know that they wholly support an increase in the award rates. Again speaking as a pharmacist owner I pay my staff above the award anyway, but I do that because I reward people that I think are doing a good job. I reward them often for time in the job and for staying with me. So retention is a big part of it because I also realise that having to retrain somebody will also cost me time and money. But - - -

PN2640

When you say the PGA doesn't wholly support an increase in the pharmacy award rates, you qualify that because you know that within the PGA membership there is some significant support for an increase in the rates of pay of pharmacists?

PN2641

VICE PRESIDENT HATCHER: You mean award rates of pay, Mr Irving?

PN2642

MR IRVING: Of award rates of pay?‑‑‑I think that you would find - I mean the PGA as we said earlier represents 70 per cent of pharmacy owners so it's a very big number of pharmacists, and I've got no doubt across that cross‑section you'd have a lot of different opinions.

PN2643

And within the PGA leadership itself there is significant division about whether or not pharmacy industry award rates should be substantially increased?

***�� ANGELO PRICOLO�� XXN MR IRVING

PN2644

MR SECK: I object. Whether or not there's division within the leadership or division within the membership is not really a relevant issue ultimately. The position which has been taken by the PGA is that there hasn't been an increase in work value and that's the question we're dealing with. Whether or not the leadership within PGA have different views can't help the Commission ultimately.

PN2645

VICE PRESIDENT HATCHER: I'll allow the question.

PN2646

MR IRVING: Can you remember the question?‑‑‑I'd like you to repeat it please.

PN2647

Okay. Within the PGA leadership itself there is a significant division about whether or not there should be a substantial increase in pharmacy industry award rates?‑‑‑I - well, I don't agree. I don't know that there's a significant division. There probably to a degree would be a division because as I said, there's a lot of people even involved in the branch committee in each state and then the national councillors, I mean there's a lot of people. So, you know, I'm not a national councillor any more so I can't tell you exactly what goes on in that office.

PN2648

Are any national councillors being called to give evidence?‑‑‑I don't know.

PN2649

Is the national secretary or any senior official?‑‑‑I can't answer that question. I don't know.

PN2650

You're the most senior official we've got on the witness list?‑‑‑Right.

PN2651

To the best of our knowledge.

PN2652

VICE PRESIDENT HATCHER: Did you say you were a national - so were you a national councillor at some stage?‑‑‑I was, yes.

PN2653

When was that?‑‑‑The previous term.

PN2654

MR IRVING: If you look at the foot of the page on page 10 there's a statement that:

PN2655

It's also important to retain talent within the profession.

***�� ANGELO PRICOLO�� XXN MR IRVING

PN2656

You'd agree that is important for the industry, isn't it?‑‑‑Yes, absolutely.

PN2657

And:

PN2658

Remuneration should adequately reflect the level of care and time provided to patients by pharmacists as well as the responsibility required of the profession.

PN2659

You'd agree with that?‑‑‑I think so, yes.

PN2660

And:

PN2661

The current pharmacy industry rates do not do that.

PN2662

You'd agree with that?‑‑‑Not necessarily. As I said, it depends what people are getting paid. As a - I don't employ one pharmacist in my pharmacy that is paid the award. I pay them all above the award.

PN2663

Do you know what the current award rate is for pharmacy interns?‑‑‑For interns? I don't know them off the top of my head, no.

PN2664

Do you know the pharmacy rate for pharmacists?‑‑‑Not off the top of my head. I know what they are roughly but I can't give you the exact number.

PN2665

You say you pay your employees above?‑‑‑Correct.

PN2666

You've got two full‑time pharmacy managers?‑‑‑Well, yes I suppose one main manager but I have a second who I would probably call the manager because they tend to do a lot of the nights. So yes.

PN2667

Compared with the award rate do you know whether or not they're 10 or 15 per cent above, or 2 per cent above, or anything of that nature?‑‑‑Probably closer to 20, yes.

PN2668

Okay, and that's true for both pharmacist managers?‑‑‑Mm‑hm.

PN2669

And what about the 10 part‑time pharmacists?‑‑‑What percentage?

***�� ANGELO PRICOLO�� XXN MR IRVING

PN2670

Yes?‑‑‑10, 15, that kind of thing.

PN2671

Okay, and the pharmacy intern?‑‑‑The pharmacy intern only does - is not my full‑time intern so I think he would probably be at the award rate, but I could be wrong, he might be just above it too.

PN2672

Have you calculated how this award application, how this amendment application might affect the workers at your workplace?‑‑‑How it would affect them? I, to be honest, don't know the quantum of change that APESMA is asking for.

PN2673

I wanted to ask you some questions about CPD?‑‑‑Mm‑hm.

PN2674

The CPD was introduced in - mandatory CPD was introduced in 2010. Is that correct?‑‑‑That sounds right.

PN2675

And it was initially 20 hours a week?‑‑‑I don't remember the exact - - -

PN2676

Sorry, 20 hours a year?‑‑‑You've got it in front of you. I don't remember the exact numbers. I mean we were obviously partaking in CPD well before that.

PN2677

There was no mandatory CPD before that?‑‑‑But - correct, yes.

PN2678

There was no obligation - - -?‑‑‑There was a strong recommendation.

PN2679

And there was no obligation within any of the - there was no requirement to engage in CPD prior to 2010?‑‑‑Well, there wasn't but I suppose it's one of those things that if something went wrong I doubt people in authority wouldn't have looked at your CPD enrolment and attachments. So there may not have been a strict mandatory legal one but I think there was encouragement and based on the fact that if something went wrong - a little bit like guidelines I suppose. We follow guidelines in a lot of the areas that we work and they aren't strictly law but people tend to follow them because just in case they end up in a room like this, the first thing people say is "Did you follow the guidelines?"

PN2680

What's wrong with a room like this? It's my workplace?‑‑‑It's a great room, as long as you don't drop water everywhere.

***�� ANGELO PRICOLO�� XXN MR IRVING

PN2681

Some people did CPDs prior to it becoming mandatory. I think we can all agree with that, but there was never any measurement of that, there was never any requirement to do that and it's now essential to become in the main a - - -?‑‑‑It's mandatory, yes.

PN2682

A pharmacist?‑‑‑Yes. Correct.

PN2683

And the amount of CPD which is required was originally 20 hours per year and it then increased to 30 hours per year and it's now 40 hours per year. You understand that?‑‑‑I understand that.

PN2684

Okay, and when it was initially introduced there was a requirement to what are now called level 1 CPD courses. That is a non-assessment based CPD course. Yes?‑‑‑Yes, the type of CPD requirement in terms of, yes, contact and whether it's face to face, whether you answer questions, whether you have an active role has changed, yes.

PN2685

It has changed by becoming more demanding?‑‑‑Yes, it probably has been a bit more demanding. Yes.

PN2686

And there's an assessment now. There wasn't an assessment before. There is an assessment as part of the CPD requirement?‑‑‑Part of it is - - -

PN2687

It's more demanding?‑‑‑Part of it is assessed, yes.

PN2688

And when you say in your statement in paragraph 14 that:

PN2689

Continuing professional development remains essential.

PN2690

You're not suggesting there that there was a requirement prior to 2010? It wasn't essential prior to 2010?‑‑‑Yes, I feel like I've answered this. It may not have been legally binding but we all as pharmacists understood that it was important to maintain our continuing professional development as a part of what we did, because everybody always wants - - -

PN2691

Sorry, could I just stop you there?‑‑‑Yes, sure.

***�� ANGELO PRICOLO�� XXN MR IRVING

PN2692

When you said "We all", you've done no research, looked at no reports, annexed no surveys. You've done no further study about any of these fields, so when you say "we" you mean you and that's it. You didn't do any of the - or you engaged in CPDs no "we as the whole industry"?‑‑‑So you asked me those questions based on this paper in front of me that I prepared and that was prepared by me with the experience of interacting in my role as a pharmacist, but also in my role actively with the PSA and the PGA where I do interact with a lot of other pharmacists. So the input - - -

PN2693

So how many - - -?‑‑‑The input that I take on comes from a lot of people that I interact with, it's not just me.

PN2694

Well, how many people do you speak about or speak to in the period 2009 to 2010 about what CPD they have done?‑‑‑I - how could I possibly give you a number on that? It's something that we often talk about because we - - -

PN2695

All right well - - -?‑‑‑We use questions to our colleagues like "Have you done enough CPD this year?" or I often get asked that question "You know, do you need to go to a conference to get some more points up?" "Do you have to read some more articles?" I get asked that question often because I do quite a few presentations and they gain a lot of points. So my answer is often, you know, "I've got heaps of points. Do you want some from me?" - that's a joke, sorry.

PN2696

Well, the answer to that question for every year before 2010 would have been "No, I do not have to because I do not have to do CPD". The conversation that you've just postulated just never occurred. It doesn't exist. It's inconceivable, isn't it?‑‑‑Well, no, sorry if I disagree but you're making it out as if we as pharmacists didn't do any CPD before 2010 because it wasn't mandatory.

PN2697

I'm just asking the questions. All right, I want to ask you about the payment for CPD. Has the PGA done any surveys or studies about the extent to which employees pay for their own CPD rather than or the employer pays for the CPD?‑‑‑So the employer?

PN2698

Yes?‑‑‑Sorry, what exactly is the question?

PN2699

Other than your personal experience about who pays for the CPDs, are you aware of any document that the PGA has which will tell us who pays for the CPDs?‑‑‑No.

PN2700

Getting back to your own experience at your own place, who pays for the CPDs for your employees?‑‑‑It varies.

***�� ANGELO PRICOLO�� XXN MR IRVING

PN2701

VICE PRESIDENT HATCHER: It varies between what and what?‑‑‑So it varies between me as the employer and the pharmacists paying for their own.

PN2702

So what do you pay for?‑‑‑ There are no rules. I recently did vaccination training. That was about a month ago and I paid for my manager to do her vaccination training and we did it together.

PN2703

But was that for CPD or for the operation of the practice?‑‑‑Both. I mean it was probably more for the operation of the practice but it was handy that we hence acquired a lot of CPD points.

PN2704

MR IRVING: And for other employees this year, they paid for their own?‑‑‑I've got another pharmacist who I've offered the vaccination training to as well. It - again it varies. I can't give you a definite answer because sometimes I'm more than happy to pay, sometimes I organise the CPD myself. So I'll get someone to come to the pharmacy and do a presentation and I invite all the pharmacists and students to come so that we have that kind of in-house facility. So it varies but I'd say that pharmacists - - -

PN2705

I didn't ask you about - - -?‑‑‑Sorry?

PN2706

I didn't ask you about pharmacists other than yourself, so?‑‑‑Sorry.

PN2707

It's all right.

PN2708

MR SECK: I thought he - - -

PN2709

THE WITNESS: I thought it was.

PN2710

MR SECK: I thought he was asking about pharmacists within the business.

PN2711

MR IRVING: Sorry, were you about to answer about pharmacists - - -?‑‑‑I was talking about - - -

PN2712

Sorry, pharmacy operators?‑‑‑I was talking about my business.

PN2713

Yes, yes, that's what I was - and had you finished your answer about your business or were you about to - - -?‑‑‑I think so, yes. No, that's fine.

***�� ANGELO PRICOLO�� XXN MR IRVING

PN2714

Okay, sorry. Dose administration aids facilitate the administration of medicines through the provision of packaging systems or compliance devices. Is that a - - -?‑‑‑Correct, yes.

PN2715

And are you aware that the dose administration aid program was evaluated as part of the third CPA?‑‑‑No.

PN2716

Were you aware that funding for the dose administration program was included as part of the fourth CPA?‑‑‑No, I didn't realise it was as far back as that.

PN2717

Okay, and were you aware that the PSA published guidelines for dose administration services from 2007?‑‑‑That sounds reasonable.

PN2718

And to the extent that those guidelines changed the practice required about dose administration aids, you accordingly changed your practice to reflect the new PSA guidelines?‑‑‑Well, I agree I changed my practice and I probably changed my practice in line with the guidelines although I changed my practice because, you know, what we do in pharmacy changes and I was probably in - was that 2007?

PN2719

Correct?‑‑‑I was probably filling a lot of dosette boxes and as time has continued, those dosette boxes have turned into Webster‑paks, so I suppose I've conformed with the PSA standards but I didn't specifically go and read the standard and change what I did because of the standard. I - to be honest I probably changed what I did in my business because that was partially an expectation.

PN2720

Could I take you to Annexure GM19, volume 2?‑‑‑Yes, and whereabouts?

PN2721

Sorry, volume 1. I'm sorry to mislead you?‑‑‑Sorry, whereabouts?

PN2722

It's tab number 19 and it's page number 15. Sorry, 2.2.19. Have you got the document there?‑‑‑Yes.

PN2723

"Guidelines and standards for pharmacists"?‑‑‑Yes.

PN2724

Yes. Appendix 1 is "DAA service funded under the fourth CPA". Do you see that there?‑‑‑Sorry, what page were we on?

PN2725

Page number 15?‑‑‑Yes.

***�� ANGELO PRICOLO�� XXN MR IRVING

PN2726

Now these are the steps that needed to be taken to ensure that the pharmacist was paid in accordance with the full CPA for this service. That's correct, isn't it?‑‑‑Yes, that's what it says.

PN2727

So you needed to be an approved pharmacy, you needed to register for approval, you needed to have access to the appropriate equipment, you have to have a private patient interview room and you needed to agree to provide the DAA service in accordance with professional service standards. Yes?‑‑‑Yes.

PN2728

You needed to agree to collect and provide de-identified patient data, you needed to perform mandatory self-audits. You needed to agree to be audited for the purpose of verifying the above eligibility criteria. Yes?‑‑‑Yes. Yes.

PN2729

Okay, and the document that I've taken you to, the "Dose Administration Aid Service" was the guideline issued by the PSA about dose administration aids. Yes?‑‑‑Yes.

PN2730

And if one goes to page 3 of that document, a statement by way of background, it talks about:

PN2731

A review of the guidelines which were originally endorsed in 1999 was prompted by a number of things including in (b) changes to practice care arrangements and legislation and the introduction of a number of new DAA systems.

PN2732

You agree there were changes in practice care arrangements and legislation?‑‑‑Yes.

PN2733

About DAA, yes?‑‑‑Yes.

PN2734

And there were an introduction of a number of new DAA systems. Do you agree with that?‑‑‑Yes.

PN2735

And it sets out on page 2 the breakdown of some of the requirements to establish and operate a modern DAA system which included "Establishing a DAA service" in paragraph 3, "Assessment of consumers" in paragraph 4 and the process for preparing the various medications dealt with in DAAs in paragraph 6. Do you see that in the table of contents on page 2?‑‑‑Well, I don't think I've got the right spot.

***�� ANGELO PRICOLO�� XXN MR IRVING

PN2736

Okay, sorry, on page 2?‑‑‑Yes, and where were you headed?

PN2737

It's just a table of contents which sets out - - -?‑‑‑I'm sorry, yes.

PN2738

- - - various aspects of what needs to be done?‑‑‑Okay, yes.

PN2739

And then the document goes through and breaks up exactly what needed to be done in relation to each level. So for example in relation to staff responsibilities, if you look at paragraph 3.4 on page 6 it says in the bottom right‑hand side:

PN2740

In addition to responsibilities associated with dispensing, a pharmacist must ...

PN2741

And then sets out five responsibilities:

PN2742

Ensuring the accuracy of DAA profile.

PN2743

That was a new responsibility imposed by these guidelines, wasn't it?‑‑‑"Ensure" - say that one again, sorry?

PN2744

"Ensuring the accuracy of the DAA profile"?‑‑‑Well, it might be a new - it might have been new to the guidelines but I can assure we were always very interested in the accuracy of the DAA.

PN2745

I'm sure you were but I'm asking you whether or not these are new responsibilities imposed through these - - -?‑‑‑I don't know.

PN2746

You don't know?‑‑‑I don't know what the previous one was, but if you say it's a new entry then I'm not denying it.

***�� ANGELO PRICOLO�� XXN MR IRVING

PN2747

I mean you have throughout your evidence in relation to DAAs and CPDs, in relation to Clozapine, in relation to a whole range of issues, given evidence to effectively say "Look, the way I've done it has been not much different over the last 20 years". That's the heart of your evidence, isn't it?‑‑‑No, no, I don't believe that I have said that. I - of course lots of things have changed in the way I have done them and they've evolved to different levels, and if you want to use an example of DAAs then of course it's - of course they've changed, of course we have different recording requirements from the first dosette boxes that I used to fill before I was even an owner. The way that we recorded, the sheets have evolved, where I sign them, who signs them, where the pharmacist signs if he's checking an intern that's filled it or a student. Of course those things are done differently and they've evolved. We have responded to for instance nursing home requirements because, you know, nursing homes funnily enough don't employ a lot of nurses any more and so a lot of the time medication needed to be packed in a way that would enable people that were discharging that medication but didn't necessarily have a medical background. So we may have to package with different information and it's - it wasn't new information for us but it was information that we needed or were requested to provide so that people at that next interface could do their job competently and better.

PN2748

So are you saying that through the introduction of these guidelines there was no change in the practice or there was some change?‑‑‑There was some change.

PN2749

Okay, and it's just a question of arguing about how much change was involved?‑‑‑Well, of course. Yes, I mean there's - I mean it's a change - I mean there's changes in the way I record things. There's changes in the information that was on the actual pack that I passed over. So of course there was change.

PN2750

And one can go through and identify all of the changes and I'll say they're huge and you'll say they're evolutionary, but you've got a particular characterisation of the extent of the change and that's articulated throughout your statement, about DAAs and a series of other issues. Is that the essential dispute between the other witness statements and you? Do you agree with that?‑‑‑It's a abroad generalisation but if you want to put it that way, that's - - -

PN2751

Well, you've said that there has been no - there has not been a significant net addition to work, accountability or responsibility?‑‑‑And I stand by that.

PN2752

You'd agree there has been a net addition to work, accountability and responsibility but you don't think it's significant?‑‑‑I think that's a reasonable statement, yes.

PN2753

VICE PRESIDENT HATCHER: Mr Pricolo, when did you become a business owner?‑‑‑I think it was '97.

PN2754

Right, thank you. And the area in which you operate in Melbourne, what's the sort of demographic of that area?‑‑‑Brunswick is very close to the city. It's more and more we're seeing young families, but it's a very vibrant area. I think people that know Melbourne would describe Brunswick as a, you know, densely populated, lots to do, lots of new businesses, a new coffee shop once a week.

***�� ANGELO PRICOLO�� XXN MR IRVING

PN2755

But reasonably affluent?‑‑‑It's becoming more affluent. It's - I mean - and I say that because property prices are skyrocketing. But it's - mixed in with that which is probably what the appeal is for many is that, you know, there's a - you know, a kaleidoscope of people living there. There's a whole range of high and low income and - - -

PN2756

And does sort of urban densification, has that increased your customer base over the 20 or so years you've operated the business?‑‑‑I don't think so. Mainly because if anything, you know, my turnover has probably decreased - or not probably, it has decreased in the last 20 years. It hasn't increased.

PN2757

What do you attribute that to you?‑‑‑Look, I'm in a particular position where I'm co-located with a medical centre so the medical centre used to be 24 hours and so was I, and over the years progressive owners of that medical centre have shrunk their hours of business. So that for instance over Easter they shut for four days over Easter. They shut for four days over Christmas, so that's four days where, you know, my business which does - whose hours never change, like I don't - I never vary my hours, is really impacted on and I - and that just doesn't impact on what happens in those four days, which is obvious, but you also lose a percentage of goodwill every time that sort of thing happens because people turn up, "Where's the doctor? Why aren't they open?" and we're very separate businesses really, and there's not much I can do to alter or to influence their hours of operation, and yet it has a huge impact on me.

PN2758

Thank you.

PN2759

MR IRVING: Sorry, Sydney Road, Brunswick?‑‑‑Yes.

PN2760

Do you know enough about Sydney to be able to say that Brunswick is a bit like Enmore in terms of a suburb?‑‑‑No. No I do not.

PN2761

All right, I have no further questions.

PN2762

VICE PRESIDENT HATCHER: Any re‑examination, Mr Seck?

RE-EXAMINATION BY MR SECK�� [3.45 PM]

PN2763

MR SECK: Just one or two questions, your Honour.

***�� ANGELO PRICOLO�� RXN MR SECK

PN2764

Mr Pricolo, you were asked questions in cross‑examination about the rates of pay for your employees and you said in relation to the intern who is not full‑time that you pay at the award rate or just above the award rate, and that differed from the percentage you paid above the award for your pharmacy managers and your part‑time pharmacists. Can you explain to the Commission why there's a difference in terms of paying above the award for interns relative to the other classifications within your pharmacies?‑‑‑Paying above the award for pharmacists?

PN2765

And why - - -?‑‑‑And not the intern?

PN2766

Well, more specifically why are you paying only at the award rate or just above it for interns?‑‑‑I suppose the intern to a degree in my eyes is probably learning more from me than the other way around in a lot of respects, although I really enjoy employing interns because they do keep you, you know, dynamic and up‑to‑date in a lot of respects. But essentially the intern is someone that most of the time you need to spend much more time with. You're constantly explaining parts of the business to them. You're often explaining a lot about medicine and rightly so, because they're very interested, they're at the start of their career, especially in the areas where you or your business has a lot more expertise. So it's difficult to - from my perspective to justify paying somebody necessarily above the award when you feel as though really you're putting a lot of time into their development, and hopefully they're getting a lot out of the experience as well as just the pay packet at the end of the day.

PN2767

Your Honour, no further questions.

PN2768

VICE PRESIDENT HATCHER: Yes.

PN2769

MR SECK: Might the witness be excused? Pardon me.

PN2770

VICE PRESIDENT HATCHER: Yes.

PN2771

Thank you very much, Mr Pricolo. You're excused and you're free to go?‑‑‑Thank you.

<THE WITNESS WITHDREW�� [3.47 PM]

PN2772

VICE PRESIDENT HATCHER: So that's all the witnesses we have for today?

PN2773

MR SECK: We do.

***�� ANGELO PRICOLO�� RXN MR SECK

PN2774

VICE PRESIDENT HATCHER: So can I just enquire how are we travelling in terms of completion of the case? What's the - - -

PN2775

MR IRVING: I think I'll be finished tomorrow morning for cross‑examination.

PN2776

VICE PRESIDENT HATCHER: So Ms Willis is giving evidence from Perth, so that's a - - -

PN2777

MR SECK: She's second, given the time difference. So we'll have Mr - I can't remember. I'm going to pronounce his name incorrectly but - - -

PN2778

VICE PRESIDENT HATCHER: Mr Loukas.

PN2779

MR SECK: Mr Loukas will be first and Ms Willis will be second.

PN2780

VICE PRESIDENT HATCHER: All right, and what's the plan then? We adjourn for the afternoon and hear submissions on Friday, or go straight into submissions?

PN2781

MR SECK: I was anticipating we'd be only on Friday but I'm in my learned friend's hands on that issue because he'll go first.

PN2782

VICE PRESIDENT HATCHER: What's your preference, Mr Irving?

PN2783

MR IRVING: I think it would assist the Commission best if we do it on Friday.

PN2784

VICE PRESIDENT HATCHER: Right.

PN2785

MR IRVING: We'll get you a document and we can work from there. I can't promise that I'll come in on Thursday night but we'll get you the document so that it will be structured.

PN2786

VICE PRESIDENT HATCHER: Yes, is it possible that we could start a bit earlier on Friday?

PN2787

MR IRVING: Yes.

PN2788

VICE PRESIDENT HATCHER: At 9 o'clock?

PN2789

MR IRVING: Yes.

PN2790

VICE PRESIDENT HATCHER: Mr Seck?

PN2791

MR SECK: Yes, that's fine. I'm not promising a document to the Commission but I'm intending to finish by Friday.

PN2792

VICE PRESIDENT HATCHER: Yes. All right.

PN2793

MR IRVING: (Indistinct).

PN2794

VICE PRESIDENT HATCHER: All right, we'll now adjourn.

ADJOURNED UNTIL THURSDAY, 10 MAY 2018 �� [3.49 PM]

LIST OF WITNESSES, EXHIBITS AND MFIs

EXHIBIT #13 BUNDLE OF COMMUNITY PHARMACY AGREEMENTS PN1548

INES KRASS, AFFIRMED............................................................................... PN1549

EXAMINATION-IN-CHIEF BY MR IRVING............................................... PN1549

EXHIBIT #14 REPORT ENTITLED "WORK VALUE OF THE COMMUNITY PHARMACIST" PREPARED BY PROFESSOR PARISA ASLANI AND PROFESSOR INNES KRASS.................................................................................................................. PN1559

EXHIBIT #15 FURTHER REPORT "WORK VALUE OF A COMMUNITY PHARMACIST PART 2 SEMI-STRUCTURED INTERVIEWS" PREPARED BY DR VIVIAN TONG, PROFESSOR ASLANI AND PROFESSOR KRASS..................................... PN1559

EXHIBIT #16 CURRICULUM VITAE OF PROFESSOR INNES KRASS PN1560

CROSS-EXAMINATION BY MR SECK........................................................ PN1562

THE WITNESS WITHDREW.......................................................................... PN1856

INES KRASS, RECALLED.............................................................................. PN1856

CROSS-EXAMINATION BY MR SECK, CONTINUING........................... PN1856

RE-EXAMINATION BY MR IRVING........................................................... PN2243

THE WITNESS WITHDREW.......................................................................... PN2250

ALEX JOHN CROWTHER, AFFIRMED...................................................... PN2280

EXAMINATION-IN-CHIEF BY MR IRVING............................................... PN2280

EXHIBIT #17 STATEMENT OF ALEX CROWTHER DATED 13/12/2017 PN2290

EXHIBIT #18 REPLY STATEMENT OF ALEX CROWTHER DATED 01/05/2018............................................................................................................................... PN2294

CROSS-EXAMINATION BY MR SECK........................................................ PN2297

RE-EXAMINATION BY MR IRVING........................................................... PN2325

THE WITNESS WITHDREW.......................................................................... PN2345

EXHIBIT #19 APESMA DOCUMENT BUNDLE......................................... PN2349

EXHIBIT #20 DOCUMENT TITLED "EARLY CAREER PHARMACIST WHITE PAPER 2017"..................................................................................................................... PN2351

ANGELO PRICOLO, SWORN......................................................................... PN2365

EXAMINATION-IN-CHIEF BY MR SECK................................................... PN2365

EXHIBIT #21 AFFIDAVIT OF ANGELO PRICOLO SWORN 18/04/2018 PN2381

CROSS-EXAMINATION BY MR IRVING.................................................... PN2383

RE-EXAMINATION BY MR SECK............................................................... PN2762

THE WITNESS WITHDREW.......................................................................... PN2771