Thursday, 3 August 2023

Bills

Drugs, Poisons and Controlled Substances Amendment (Authorising Pharmacists) Bill 2023

Second reading

Debate resumed on motion of Ingrid Stitt:

That the bill be now read a second time.

Georgie CROZIER (Southern Metropolitan) (10:06): I rise to speak to the Drugs, Poisons and Controlled Substances Amendment (Authorising Pharmacists) Bill 2023. At the outset I want to just put on record my thanks to all the stakeholders that have spoken to me at length over the last few months about this bill. That includes obviously those who are going to be directly impacted by this change that the government is proposing today: the Pharmacy Guild of Australia, the AMA, the Pharmaceutical Society of Australia and a number of other stakeholders. I also want to thank the government for providing information as requested to clarify many of those points of contention around this bill – and there have been many areas of contention from competing sides, from the pharmacists to the AMA, in working out the best way forward. I want to also say that I have appreciated the extensive consultation that I have undertaken. Pharmacists from the around the state have also contacted me and we have spoken through the issues, so I do appreciate all of that input.

What this bill does is amend the Drugs, Poisons and Controlled Substances Act 1981 to introduce new regulation powers to enable pharmacists to supply, dispense, administer, use or sell schedule 4 poisons without a prescription in certain circumstances. Essentially what the government is intending to do here is allow pharmacists to supply and dispense a number of selected medications that relate to the treatment of minor skin conditions, the treatment of uncomplicated urinary tract infections and the reissuing of oral contraceptives for women. These are minor ailments, but they cannot be underestimated or just brushed off. They should be looked at in the context of them being a significant health issue for individuals, and for that reason they need to be monitored very carefully and they need to be followed up. A lot of adverse reactions and adverse outcomes can occur if that is not undertaken appropriately. The government has indicated that there will be evaluation and there will be a follow-up, and we will challenge that in the committee stage to enable us to tease this out a little bit more.

But I do understand why the government is introducing this bill. It is important for accessibility, especially for many women that are finding what every Victorian is finding – that we do have many, many issues within our health system and there just is not the accessibility around the state, whether that is through GP practices or other health services, because of the dire situation that our health system is in.

In saying that, there are shortages of GPs right around the country, and that has been recognised. What the government is intending to bring in today, or this debate that we are having today, has been looked at in other jurisdictions, not only in this country but also internationally. There is quite a lot of data that I understand has come into why the governments not only here in Victoria but in New South Wales, South Australia and Queensland are looking at this issue. The UK, Canada and New Zealand have undertaken similar pilots and trials on these specific areas and have had favourable results. So that is a good start, but that does not take away from the need for Victoria to ensure patient safety.

I have spoken at length to the person who undertook the evaluation in Queensland about the Queensland pilot to understand what happened in Queensland and what they are intending to further do. New South Wales have got a different system in place – they are undertaking a clinical trial – and South Australia has a parliamentary inquiry underway. So you can see that there are issues around the country but they are being looked at in various forms. The government’s reasoning to me and those that were on the various briefings that we had around this bill was that information is coming in from the other jurisdictions and therefore we do not need to duplicate it. I do appreciate and understand that. As I said, I think patient safety is the thing that I am most concerned about, and I think others would be too, and that is why there needs to be a proper evaluation process to ensure that that follow-up that the government says will occur does occur.

As I said, we know that there are significant issues within our health system, and we know that especially in parts of rural and regional Victoria the health services just are not there. When people turn up to emergency departments to access health services in those facilities, there are long wait times and delays, and unfortunately too many poor outcomes are occurring because of the broken health system here in Victoria. I cannot see that getting any better any time soon. The issues around health are very, very significant in this state. It has been years of underinvestment, and we are really paying the price for that now. I have been on the phone this morning and heard more alarming stories about what is occurring unfortunately in our major hospitals here in Victoria. As a former nurse and a former midwife who has worked in those hospitals, I find extraordinary the stories that I am hearing. That does concern me. Our emergency departments are very well clogged, and I have been saying for years, especially through COVID: if you delay treatment, if you delay screenings, if you delay accessibility, people will get sicker – and they are. We know that.

The extensive lockdowns that occurred here in Victoria led to so many issues right across the system, and we are paying a price for that now. It is unfortunate that this government refused to have any sort of inquiry into COVID. The royal commission that I was calling for in September 2020 because of the mismanagement – well, that only got worse over the coming years. I still say there should have been some inquiry. I was absolutely appalled with the response that the Parliament received from the government about the inquiry that I was on with the Pandemic Declaration Accountability and Oversight Committee looking into the government’s pandemic declaration. That committee looked into, as a requirement of that legislation, some of those issues. There was one line about what they were going to do. Now, I digress slightly from this debate, but the reason I am raising it is because it is symptomatic of it, and it just shows the extent of where our health system is at despite the efforts of those clinicians, who are doing a remarkable job. They are the stories I am hearing, and they are stories I am hearing from the patients too, who are saying to me, you know, you go into the emergency departments and the doctors and nurses are just fantastic, but what happens after that is very alarming. So we have got real concerns around Victoria’s health system, and they remain.

What this will do is alleviate a lot of pressures within those emergency departments for people accessing those services at a time when they might have a urinary tract infection – that is not an uncommon ailment; it can obviously become a serious condition if it is untreated – or for some other underlying physiological condition or some other medical issue that is present. Nevertheless this is up to the government to ensure those safeguards are in place to enable those patients to have those conditions picked up and appropriately referred and treated.

Again can I say that it is my understanding that the Victorian pilot is a 12-month pilot that starts on 1 October. I just need to get some clarification, because I have received information from the government that does not quite spell that out – I will ask that in committee – in terms of what the government is trying to do to give Victorians accessibility to a number of services, namely pharmacists, to enable them to dispense and supply medications for the conditions that I have outlined, or the oral contraceptive pill in the case of women being able to access that without having to wait weeks for a GP appointment and get a prescription.

I would also like to highlight that those pharmacists that work in GP clinics do not have the same rights as community pharmacists. That has been an issue that has been raised with me, and I do want to thank those that have spoken to me. They are concerned that we will be coming back in 12 months time and sorting out this issue around prescribing rights. They have been very clear on that. They have been saying that they think there is a shortfall in this piece of legislation that we are debating and that that potentially could be an issue for government that the government needs to work through.

Initially when I was having all these discussions this was something that I thought was a relatively straightforward bill. Because of all these stakeholders that came to me, it was clear that there were many questions that needed to be clarified and raised, and I am pleased that the stakeholders have provided me with that information, which I will endeavour to get clarification on through the committee stage and the government’s reassurance of the efficacy and the safety of this pilot that they intend to commence in just a few weeks time, on 1 October.

So those are the concerns that I have around elements of this bill. In saying that, I do understand the intent of why the government is proposing the legislation and what it is trying to achieve to enable greater accessibility for Victorians under a very stressed health system and give them that ability. We know in regional and rural Victoria services are declining. I am alarmed by what I am hearing around the potential for amalgamations of our hospitals in country Victoria, and I think that will further diminish services in those regional areas. I think that is a very big concern to small country towns. I grew up in far western Victoria. I know what it is actually like to have to access specialist care in Melbourne. I understand the importance of having local services close to where you live. Once they lose those services, those Victorians will have to travel further. That is a very big cost to them, and I do not know that people in metropolitan Melbourne necessarily understand exactly what rural and regional Victorians have to do to get to appropriate health care and access their basic services such as health care. I want to put on record that I do appreciate the struggles that many regions within Victoria are having, and I have said many, many times that the decisions made in 50 Lonsdale Street – they need to get outside of the tram tracks and really understand what is actually happening in regional Victoria. I do not believe a big centralised bureaucracy is the way to go to deliver health services to local communities.

I understand that this will give greater accessibility for those Victorians to enable them to be seen by pharmacists to be treated for minor skin conditions and to be given antibiotics for urinary tract infections and for skin conditions that otherwise would need a prescription when there are long wait times for Victorians to be able to access a GP. With those words, I will say that I look forward to the committee stage of the bill to be able to get to some of the further questions that I have regarding this bill.

Sarah MANSFIELD (Western Victoria) (10:21): I rise today to speak to the Drugs, Poisons and Controlled Substances Amendment (Authorising Pharmacists) Bill 2023. This legislation is being tabled, as we have heard, for the purpose of enabling a pilot program whereby pharmacists can dispense certain schedule 4 medications, which are normally prescription-only medications, without a script. Everyone here I think knows that I love talking about the drugs and poisons schedule, so here is another opportunity.

Before I begin to speak on the legislation at hand, for transparency, I am a fellow and a member of the Royal Australian College of General Practitioners. They are a relevant stakeholder in this pilot, but I do not stand to gain any personal benefit from the outcome of this legislation.

After much deliberation the Greens will be supporting this bill, because fundamentally we believe in improving access to health care. As a health practitioner I know all too well the consequences of delayed access to primary care, and in particular this pilot has potential to improve access for women for certain issues and for people in areas with limited access to primary care, like rural and regional communities. We fully support the principle of maximising access to health care by using all the skills available to us in our health workforce, and pharmacists are well placed to take on extended roles. I have huge respect for pharmacists, stemming from the almost 10 years that I spent from age 15 working in community pharmacies and then from my role as a doctor, where I continued to work closely with pharmacists. They are incredibly knowledgeable and an indispensable part of our health system.

We will also be supporting this because it is enabling a pilot program. There is potential to learn from the experience prior to any ongoing commitment, provided it is adequately conducted and evaluated. However, I will be using this opportunity to put a range of concerns that we have on the record, and I hope that the government will take these into consideration as they roll out the pharmacy pilot program that this legislation supports.

Just as we have heard from Ms Crozier, the Greens too have been consulting broadly on this and have heard from a very wide range of stakeholders who have raised a whole spectrum of concerns about this pilot. While various forms of what is essentially pharmacy prescribing have been done in other jurisdictions, it has not been done before in the Victorian context, and context is really important. Many overseas examples have occurred in systems that are quite different from the disconnected private retail pharmacy setting that dominates in Victoria. In Victoria we do have a very fragmented healthcare system, where patients experience the consequences of poor integration and record systems that do not support holistic team care.

I am also concerned about a general shift in health care, which is becoming increasingly transactional and where the customer service experience is prioritised over universal access, quality, safety, continuity of care and the fair distribution of scarce health resources. We know that a transactional, fragmented healthcare system is the opposite of where we should be headed if we want good health outcomes. The Greens have concerns that if not done properly this pilot may undermine efforts to improve integration across different types of health services, ensure fair access for everyone and prioritise safety and quality of care. In an ideal world everyone would receive timely gold-standard comprehensive care in a general practice setting with continuity of care, but we recognise that we live in the real world. Access is challenging. We do not have enough GPs, especially in rural and regional Victoria.

The quality of care also varies. There is no doubt that with a robust protocol many people accessing pharmacy care will get the right treatment and in some cases better care than they might otherwise, but for those who do not receive the right treatment there is the risk of further delay getting appropriate care, and this may lead to adverse consequences. It is essential that these impacts are considered in the evaluation.

An area where there is a key risk of not receiving the right treatment is that this pilot will enable pharmacists to dispense antibiotics for a urinary tract infection both without a prescription and without diagnostic testing. Now, almost every GP I have mentioned this pilot to says the same thing, and I know this from my own experience to be true: that very often when people think they have a urinary tract infection they actually do not. For example, many common sexually transmitted infections present with symptoms similar to a UTI. Diabetes can first present with symptoms that seem like a urinary tract infection, and you often do not find out until you do testing and see sugar in the urine. Another example: women who are menopausal can have symptoms that are very similar to a urinary tract infection. But these things can only be discovered by taking a thorough history and doing a physical examination and testing – not to mention that the bacteria that cause urinary tract infections are increasingly resistant to many common antibiotics. With this pilot, if the wrong antibiotic is dispensed we will not know until they see a GP a few days later and then get testing, which will actually further delay them getting the care that they need. The risk of harm to patients can and should be minimised through robust referral pathways, and the dispensing of medication by pharmacists needs timely and meaningful follow-up and best practice information recording. The evaluation should also be looking at all of these issues.

Another aspect of the pilot will be dispensing repeat oral contraceptive pills. While improved access to contraception is something we wholeheartedly support, this pilot may inadvertently limit opportunities for contraceptive counselling, especially where pharmacists are engaging with consumers in a retail setting. Our federal colleagues recently spearheaded a Senate inquiry into universal access to reproductive health care. In their final report they acknowledge that all levels of government must work towards increasing access to the full suite of contraceptive options. While oral contraceptive pills continue to be the most widely used in Victoria, we need to do much more to increase the uptake of long-acting reversible contraceptives, known as LARCs. They are more affordable and more effective. These include things like intra-uterine devices, hormonal implants and hormone injections. Australia actually has one of the lowest rates of LARC use compared to similar wealthy countries. We have only got 11 per cent of women using LARCs compared to 46 per cent in the UK. This pilot will be limited in its capacity to support patients to pursue alternatives such as LARCs. This is because a GP visit for a repeat pill script is actually a prime opportunity to review the choice of contraceptive and introduce the idea of a LARC, not to mention screen for a range of other health issues. Pharmacists are actually well placed to have this conversation as well, provided they have the appropriate space and training. It is not actually something that this pilot is considering, and we think this is a missed opportunity. We hope it is something that will be looked at in the future.

In terms of the practical rollout of this pilot, there are many unanswered questions, and some of those I will endeavour to interrogate during the committee stage. There is a real lack of detail about how this will work at the pharmacy level. For example, how will consumers know where and when they can access this service when they need it given that not all pharmacists will automatically be able to participate in this program? They have to undertake training, and they have to do separate modules for each part of this program. For example, there might be five pharmacists employed at a pharmacy: one of them might have done the contraceptive training, one of them might have done the urinary tract infection training, one of them might have done travel vaccines and the others might not have done any training. If you are a consumer and you are thinking, ‘I can go to my local pharmacy and get a script for antibiotics for a urinary tract infection,’ that will not necessarily be the case. So there is a logistics issue there that needs to be worked through.

A really big one is about what record keeping will take place. We have had debates in this chamber about the state of health information records, particularly the issues with them in Victoria. Pharmacists will not have access to a person’s full medical record available, so they will not be able to check their past history. That is a really important thing to do before you prescribe a medication – to check someone’s history. You look at adverse reactions and you look at other medical conditions that might be relevant in your choice of treatment. Pharmacists do not have that access. They might have their prescribing history if they have been to that pharmacy before.

In terms of communicating back to other health providers what has happened in that interaction, we have been advised that pharmacies will upload this to My Health Record. I do not know what they will upload other than the medication that has been dispensed, but we know that not everyone has My Health Record, and it is not clear how a person’s regular GP will be notified of their involvement in this pilot program. We think that patients at the very least should be given some sort of record themselves to aid them in seeking any follow-up care they may require.

We also want to know how privacy and confidentiality will be ensured if the pharmacy does not have a private room to consult in, which is really common in a lot of pharmacies. Again, from my experience working in a pharmacy setting, I have been there in pharmacies that have been involved in dispensing emergency contraception. It is a great thing that you can get this over the counter at a pharmacy, but it is something that involves some sensitive conversations, and in a lot of pharmacy settings that conversation occurs at a desk with a partition to try and keep it private. It is really not a very private setting. When you are talking about things like urinary tract infections, there are some important, sensitive, embarrassing questions that you might have to ask someone. Similarly with repeat contraception pills, there may be some sensitive conversations that need to take place. So we really want to ensure that pharmacies are supported to provide that service in a confidential and private space.

Who is providing indemnity insurance to participating pharmacists? That is an outstanding question we would really like to understand. And will potential conflicts of interest arise? We need to seek some clarity over how pharmacists will be paid for providing this service. If the income is attached to dispensing the medication rather than just for the provision of a service, there is the potential for a conflict of interest or perhaps for there to be an incentive to dispense medication when perhaps the best outcome of that interaction is just advice rather than a prescription. If there is income attached to providing a prescription, there is that potential for it to create a conflict of interest.

Many of the concerns that I have outlined, and more, have been identified by a broad range of stakeholders, most of which, I am pleased to see, are represented on the various advisory bodies that the Department of Health has established to work with on developing this pilot. We do believe that all of these issues could potentially be worked through, but we think they need a bit more time, rather than rushing to meet an arbitrary deadline of 1 October. 1 October, it seems, was an election commitment. We understand that it is important to set deadlines, but if you are not able to meet them and do things properly, there is no harm in pushing them back a bit. There are widespread concerns from all stakeholders that this October start date is just too soon, and the pilot’s design should not suffer as a result of meeting this arbitrary deadline. There are many stakeholders who want this to succeed, but rushing will potentially set it up to fail, and we would really urge the government to take the necessary time. If this means pushing back the start date beyond 1 October, then that is what should be done. If the government is intent on powering ahead, at the very least we need a robust and transparent evaluation. The evaluation must be independent and well designed and consider a range of clinical safety measures and clinical outcomes, the positive and negative impacts of the pilot and also, ideally, a cost–benefit analysis, although I am not sure that is on the cards. Crucially, the findings must be made publicly available so they can be subject to scrutiny. This is important regardless of what the findings are.

The general consensus from all stakeholders and community members is that this needs to be done right. While there are plenty of complexities at play with rolling out a pilot such as this, the bottom line is that right now people are struggling to access basic care and this sort of program might help, but only if it is done well. We really look forward to seeing the results of a robust evaluation if this legislation passes today. I will also be seeking further clarification and assurances during the committee stage.

Tom McINTOSH (Eastern Victoria) (10:35): I am glad to speak today on the Drugs, Poisons and Controlled Substances Amendment (Authorising Pharmacists) Bill 2023 and to be following on from Ms Crozier, who spoke about growing up in western Victoria and the challenges that poses to health access. I will pick up on some of those points as we go. It was good to hear Dr Mansfield raising her detailed points. I think it highlights the benefits of having a range of people in here with various backgrounds and professional skills as they come in, but I think it also highlights the importance of the decision that has been rightly made around ensuring that this is a pilot program so it can be observed before we hopefully move to a full delivery of the program.

There is $20 million for the pilot for 12 months, with community pharmacies to deliver primary health care to Victorians, which includes oral contraceptives and treatment for mild skin conditions and urinary tract infections, and they will also help with travel and health vaccines, including hepatitis A, hepatitis B and typhoid. One of the big, big bonuses of this, which is very obvious but really, really meaningful to people, is the fact that it saves people time and it saves people money. Not only that, it takes pressure off our health services. We know that a lot of particularly GPs are facing stress. They have had a decade of lack of investment federally, and that has built up and exerted pressure. So programs like this are really, really important to help people but to help people within our health system as well.

Of course what is fantastic is it is about women. Women make up 52 per cent of our population. Traditionally, we have had a situation where men will not turn up to get health care and the support they need, and when women try they have often been turned away or given incorrect advice or those treating them have not perhaps had the understanding, lived experiences or perhaps the empathy to ensure that women are getting the right advice and leaving with what they need. I was actually just talking to a colleague of mine this morning – I just bumped into her in the stairwell and said I was off to do this – and she talked about the medical misogyny that has existed. A simple point she made was ‍– I have not fact-checked this, but I will take her word for it – the fact that paracetamol was never tested on women; it was tested on men. We have had decades and decades of that ingrained medical misogyny, as I said – and some other things I will talk through as I go – resulting in women not being able to obtain the support they need and being undiagnosed and turned away.

I will come back to the substance of the bill shortly, but I just want to touch on the comments Ms Crozier made about the importance of health care and support regionally. I am so delighted that this government has made an investment in 20 comprehensive women’s health clinics. Two of those are in my electorate of Eastern Victoria. It is just so important for women living regionally, and I will come to this a bit later as well. We know there are more challenges for them around some of the stigmas, around the conversations, which are already difficult conversations with some of the items we are talking about, but even more so when they are living in communities where people know each other more, where there are distances to travel – all these things that compound into women getting the health support they need. The statistics around some of this stuff are pretty incredible.

We talk about women being overlooked and undiagnosed, women being sent home and finding it draining and demoralising, so the fact that the services I have just outlined have that wraparound support for a number of issues, from contraception to pelvic pain – and I will talk through those – just is such a step forward, to have everything in the one place. I was actually talking about this in another contribution yesterday – it just makes sense that our services meet community where they are and that we try and have many touchpoints for people to access those services where they are.

Two hundred thousand women in Victoria suffer from endometriosis, and on average it takes seven years from the onset of symptoms to get a diagnosis – seven years of being bounced around, in pain. And 85 per cent of menopausal women suffer symptoms. Just as I wrap up talking about these comprehensive women’s healthcare clinics, perhaps to many in here it will not be as much of a whack in the face as it is for me, but I just find those statistics incredible. It just reinforces how proud I am that this government is making these investments in women’s health. Issues that affect women are not niche issues – as I said before, they are 52 per cent of the population – so it is fantastic that we are stepping up and addressing them.

These clinics will treat a variety of things – including period pain; fibroids; as I said before, endometriosis; pelvic pain; and polycystic ovary syndrome – and manage the symptoms of menopause. We are also going to have the mobile health clinics for those women who cannot reach the clinics, as I talked about before – they will be there to supplement it – and there are also going to be specialised supports for Indigenous women, which I am also very proud of.

It does flow on from the leadership this government has delivered around looking at women’s issues and also around some of the greater difficulties and the entrenched difficulties, particularly when we are talking about regional Victoria, with family violence. I recently met with Gippsland Women’s Health CEO Kate Graham, and we spoke about the challenges that women in regional areas still face and how we still have much to do, but these programs have worked; they are making meaningful differences to women living in our communities. I think we are also, through these conversations, breaking down associated stigmas to make sure that women, and particularly young women, feel comfortable to come forward and have these conversations.

We have got another $20.7 million for period products in schools. I spoke yesterday on another motion in relation to cost-of-living pressures on families. This is a great way to support families and support young women with something that is just so, so essential to them, and it provides confidence for our students in going to school. And as I said, it is just great that there is another opportunity for women’s health to be discussed so there is not awkwardness around it, particularly for men, for dads and family members, because there should not be. It should be something that we are all comfortable talking about, because as I said, it affects 52 per cent of the population.

Before I do come back to the bill I just want to touch on this focus on women through this government, because monocultures are never a good thing. I do not think it matters whether you are talking about a cultural monoculture, a gendered monoculture; whatever it is, getting a diversity of views and inputs is really, really important. We look at the Parliament and the number of women that are entering. We look at the cabinet – women are over 50 per cent of the cabinet. We look at our state boards – the decision, the commitment that has been made to get women onto our boards and the change that is occurring through that. We are seeing those numbers rise every single year. Funnily enough, when you get more women into these positions, you get better outcomes for women. It is the same for anything. Back to that monocultural point, when you get people making decisions or providing advice about issues that affect them – surprise, surprise – you get better outcomes for them.

The last point I will make is that – and I am quite aware I am standing here as a white male saying all these things – 20 years ago when I worked in construction there was not a woman to be seen. I was talking to a CFMEU organiser on the phone this morning as I happened to go past a construction site and saw some women working on traffic management, and I just said, ‘I’m going to speak on this bill this morning.’ I just raised it. He was talking about the absolute change across the industry. It is supported by unions, it is supported by builders, and I think the success is enjoyed by everyone. He talked about the maturity that is now in the industry. Some of the things that were happening 20 years ago that you would see on site just do not exist anymore, and everybody has benefited from it. I think that ‘maturity’ is a really good word, and I am proud the construction industry has such good pay and conditions so that Victorian families can benefit from that. He just talked about the benefits there are to women and the fact that in the last five years job sharing has become such an accepted thing. We know it has happened in other industries. It is still difficult, but it has been really, really heavily adopted in the construction industry. Builders and unions are on board with it. At times you have got up to three people, predominantly women, sharing one job, working, say, a Monday, Tuesday, Wednesday, Thursday, and a Friday and Saturday, getting that good pay, getting that money to help them, whether as single parents or for their family, to support their kids, but making sure there is still time for their kids, because both sides of the equation, men and women, need to make sure that they have time for their kids, particularly in those early years. I just wanted to mention that because I think it is a really wonderful thing that is happening.

As I said, it is $20 million for this 12-month pilot. It is community pharmacists that are going to be involved in it, and I think that is really important for Victorians who want to use this service as well, because it is those relationships that exist with community pharmacists that make it easier for people to come forward, as Dr Mansfield said, and perhaps have some of these challenging conversations around some of the items that are supported and provided. But it is also great that travel vaccines are there; I know for me and my family the difficulty of trying to get the kids organised and get them along and get it all to happen before you go on a holiday.

It just makes sense, I think, the fact that this bill is not about vested interests. It is not about who wins or loses, it is about what the best outcome is for people, what the best outcome is for Victorians. That is why it just makes such good sense. The fact that the pilot is there for 12 months gives us a very good opportunity to have a look at how it performs and any issues. Obviously, from a health perspective we want to be absolutely thorough in ensuring that Victorians are getting the best advice, but there is no doubt that Victorians are going to greatly benefit from the cost saving and time saving, and as we have talked about before with regional Victorians, it is incredibly important just to get access, full stop.

I will just touch on a few more points that I want to speak to before I wrap up. Dr Mansfield before touched on who is going to be involved. The pilot’s design will be informed by an advisory group, and that is going to represent key stakeholders. That will include pharmacists, doctors, the community and, importantly, as I outlined before, consumers. The medicines prescribed in the pilot for the selected health conditions and the relevant prescribing protocols will be consistent with those recommended by the latest Australian clinical guidelines. Community pharmacists and pharmacies will have to meet certain conditions before they can provide services as part of the pilot, to ensure safe patient care and familiarity with the specific requirements of the pilot. All participating pharmacists will be required to complete mandatory training before providing any services, and participating pharmacists will be provided with guidance and protocols as to who is eligible to receive treatment and who must be referred to a doctor. I think that outlines just in a snapshot the thought and the detail that is going into this program of work.

I am going to wrap up. As I said, I think it is an incredible thing. I think it is going to benefit so many people, it is going to have good health outcomes and it is going to support people to get health access. It is going to support people to have conversations and to get along and get health support.

Melina BATH (Eastern Victoria) (10:50): I am pleased to rise this morning to speak on the Drugs, Poisons and Controlled Substances Amendment (Authorising Pharmacists) Bill 2023. I do so because it provides me the opportunity to talk about rural and regional health, rural and regional pharmacies and our doctors, GPs and health system. Before I drill down into some of the issues that I want to raise before the house, I will speak on the purpose of the bill. That is why we are here this morning. It is to amend the Drugs, Poisons and Controlled Substances Act 1981 to allow community pharmacists to be legally authorised to supply and dispense and therefore administer, through their front of house, certain prescribed medicines without a prescription as part of a 12-month community pilot. We have heard about the pilot from Ms Crozier and other people today, and it is starting in only a few months time. Now, the key thing about this and the important thing is that they can supply and dispense specific and particular medications for the treatment of minor skin disorders and for the treatment of uncomplicated urinary tract infections (UTIs) and – this is very important in my mind – reissue the oral contraceptive pill for women.

It will also expand the role that community pharmacists play in terms of immunisation for travel and public health vaccines. We have very much seen the role that they played during the COVID pandemic and the opportunities for access that people had. Rather than going to a large tent in a large town they could after a time go into their local pharmacy and have that COVID vaccine, and many of our community certainly took up that option.

The pilot is very important. I want to put on record that I know Ms Crozier has had extensive consultation with stakeholder groups: the AMA; the Royal Australian College of General Practitioners, and it is interesting that we have got a member of that organisation in our house – it shows the good diversity of the people within this place who can provide comment and perspective; the pharmacy guild, and I know the Nationals have always had good communication with the pharmacy guild, as they have across the board, providing their views on a variety of topics and subjects and policies; and also the Pharmaceutical Society of Australia. It is very important to get their feedback.

There is not a week that goes by in my electorate office and in my inbox when I do not hear about Victorians who are under the strain of a pressured, unstable and difficult health system. It is always that road that as an MP you try to take to support the patient, the person or the constituent, who is frustrated with being on a waitlist that is taking an eternity, to support them and advocate for them but also to understand that our hospital system is continually under pressure, as are our CEOs, nursing staff, doctors and physicians constantly. The list is so long. Never did we see that more than during the COVID pandemic when the elective surgery list, which was postponed, ended up in many cases being an emergency list, because people’s conditions exacerbated and worsened to a point where they were no longer elective but life threatening. So to be able to have legislation that can in one segment take some pressure off our very challenged health system is a good thing – with parameters and with clauses in there.

Our GPs and our hospital staff do an amazing role. Our GPs are frequently under the pump, and I am sure anybody living in rural and regional Victoria will understand that when you ring up to make an appointment with I will say your doctor – if you can have your doctor – it can be a month’s wait at least for various conditions. These can be potentially – not the contraceptive pill but urinary tract infections and minor skin disorders – acute conditions. They need to be seen within days to avoid that walk-in to the emergency department. I know many constituents have raised this with me. You do not want to get to an illness state, because it then becomes critically health impacting. If you cannot get in to your doctor, you try and see another doctor, and although the front desk is very supportive and will try and fit you in, sometimes there is just not an available space for that day or for the rest of the week. These are the challenges we certainly face in rural and regional Victoria. So where you have a condition that is reasonably assessable, that is not life-threatening, as listed here, it is important to have another opportunity through a professional. We know pharmacists have to go through many, many, many years to become pharmacists and to enter into their profession.

Speaking from experience in my region, in my local home town, there is a fantastic pharmacist who is just about to hand over his long reign in his pharmacy – Brett Nagel. He said he walks down the street and he literally knows every name of every person in our town and our outlying communities, because he has served them so well for so long. It is wonderful to see, and this is the case in other pharmacies as well. There is a new breed coming in. If you can attract pharmacists to our regions, they come for their profession but they can stay for their lifestyle. We certainly embrace new professionals in the health departments for eternity. He is looking to transition at the moment into retirement, and there are some fantastic young people coming into our area. They are employers in our towns; community pharmacists are trusted, and they have that trusted advice as well.

Interestingly, about 25 years ago or more, when I was a young woman, I ran a health food shop. I owned and operated a health food shop. The difference of opinion in the medical profession from then to now is quite a quantum jump. Years ago – and these were TGA-approved products – vitamins and minerals were not really in our pharmacies. They were not really knowledgeable within the medical profession. You would recommend things like glucosamine, chondroitin and methylsulfonylmethane for arthritis – non-life-threatening but really supportive in terms of preventative, complementary medicine. People never adopted them. The medical profession was like, ‘What’s this?’ I actually went to my doctor for various reasons the other day and talked about my ankle that had been inflamed since Kokoda, and he said, ‘Have you tried glucosamine and chondroitin?’ So there seems to have been a quantum shift, and that is really important because the key thing about all medicine is about keeping people out of hospitals, supporting them before they get to a chronic stage, and that is really important.

It is also important that this is reasonable legislation and that a pilot will be assessed. I note other jurisdictions in different states. The Queensland government has conducted a two-year pilot program that started in 2020, so it has concluded. I will put on record for the minister who is going to cover off on the committee of the whole that in some of the documentation that I think is available they talk about the cost, the $19 million up-front, of this pilot, and then they talk about the costings expected to deliver various thousands of repeat prescriptions for oral contraceptives – I will not read in the finites ‍– various treatments for UTIs, treatments for minor skin conditions and travel vaccinations. I am interested to know whether this government has looked at Queensland to see if their modelling on a 50 per cent uptake is actually accurate within that jurisdiction. So what has the government learned and what can it learn? Has it asked any questions about the Queensland experience and how that can inform better practice in this piece of legislation? I am putting on record that question, if the minister could respond to that.

In speaking with some of my local pharmacies, I had a communication with a pharmacy in San Remo, a great little place down there, where people who love fishing love to live, love to retire, love to holiday and love to have good service from the San Remo pharmacist. While this is a pharmacy pilot and it is designed to take that pressure off GPs and hospital emergency departments, he said that his pharmacy already consults with patients and already diverts people away from hospitals. He said because of the GP shortages – and he acknowledges that in that Bass Coast area as well – patients will come in anyway; they cannot get into a GP or the hospital, so they come in. So the service is actually helping to reduce the costs and reduce the pressure on our hospitals. He also identified that pharmacists are under increasing pressure from that federal government 60-day dispensing policy. That is putting negative pressure, he said, on the pharmacists due to a number of factors, but certainly the lack of foot traffic that that 60-day prescription can now afford. There are pluses and minuses, and I will not go into that in a deep way because it is not really the intent of this bill, but I will just say that whilst it is a federal government situation, and I understand that, the government, in its deliberations and implementation of this bill, really needs to be mindful of those pressures that can be placed on pharmacists in their service and to continue negotiations on how they can still serve our communities.

In terms of the importance of training and accreditation, it certainly is important that the government, in this pilot, still have certainly rigour around the training or the implementation of this bill and the follow-up. I know we had a conversation in here just before about that assessment and the monitoring of scripts going out et cetera.

In conclusion, this is something that I think we need to support in terms of looking at the pilot program. The Nationals will not be opposing this. We will be interested to see those questions. This should never replace the important work that doctors do in assessing and analysing and a fulsome experience in terms of people’s medical health. But there can be these non-life-threatening issues, and in the case of the pill I just want to stress that for my value, it is that represcription – so, providing that service. UTIs can be so incredibly debilitating, not only for young women; certainly you tend to see it in ageing women or postmenopausal women. It needs to be addressed because that can be very crippling, and you can end up having that life-threatening situation. I know that from speaking to many constituents. So with that, I will be looking forward to the committee stage of the bill.

Adem SOMYUREK (Northern Metropolitan) (11:04): I think this bill is a step in the right direction. I think it is well overdue in fact. I have always disliked the requirement to go back to a doctor to get a prescription on something that you have had prescribed to you for a number of years and no doubt you will continue to have prescribed to you over a number of years. That, to me, seemed like it was a waste of time, a waste of money and a waste of precious medical resources.

For example, this bill does not cover my particular problem. I take blood pressure tablets. I have to rock up every couple of months to get prescribed blood pressure tablets. I wait out in the area to be seen by the doctor. I will wait an hour, and then I will go in for 2 minutes, get prescribed my medication and then go out again. I understand what the opposition parties are saying, the Greens and perhaps the Liberal Party, about there maybe being more complicating factors sometimes that doctors need to check. Maybe conscientious doctors do those check-ups, but the doctors that I have seen just write the prescription for you, so it actually does not matter.

I think this is a good bill and I think it does provide access to medication for people who need it, and I think it will make our health system much more efficient. I commend the bill to the house.

John BERGER (Southern Metropolitan) (11:06): I rise to speak on the Drugs, Poisons and Controlled Substances Amendment (Authorising Pharmacists) Bill 2023. This bill will introduce minor yet important changes to the Drugs, Poisons and Controlled Substances Act 1981 which will allow community pharmacists a far better platform to provide health care. The bill will authorise a 12-month pilot with three principal areas of focus: continued supply of oral contraception, treatment of some skin conditions and antibiotics for certain urinary tract infections (UTIs). It also includes an expansion of the vaccines that pharmacists are authorised to administer. This bill is an important step in reducing the strain on our GPs by allowing pharmacists to prescribe medications for simple diseases, which can reduce the total stress on our healthcare system and free up GPs for more serious matters.

The community pharmacist statewide pilot will ensure that health care and medication are more accessible to Victorians who truly need them. This bill is also a way that we, the Andrews Labor government, are honouring the promise that we brought to Victoria in the 2022 election: the promise that we would back pharmacists. Much like the Andrews Labor government, community pharmacists do what matters.

I will explain more specifically how the bill goes about achieving this by acquitting pharmacists with the necessary means to deliver uncomplicated but essential procedures. This will be achieved by establishing a strong regulatory body for pharmacists to ensure that they are legally authorised to administer these services, which include pharmacists writing prescriptions, administering vaccines and even treating mild, uncomplicated medical conditions. This is all about ensuring that primary health care is as strong as it possibly can be, especially in lower risk cases and for conditions that have the potential to become complicated. It is essential that these be treated as soon as possible, not only for the individuals suffering from the condition but also for the health system. If it is easily avoidable, then we do not want the resources to be focused on a condition that could have been simply treated earlier.

Under these amendments pharmacists will be able to directly prescribe medications like antibiotics for uncomplicated UTIs or oral contraceptive pills, both very common medications. This will decrease the number of individuals requiring doctors appointments. Due to this, the bill will expand the accessibility of certain medicines and make the process of receiving treatment less stressful for Victorians who tend to already be in extremely stressful circumstances. Navigating the health system is always a stressful situation, which is why it is essential that we have a government that recognises this and does everything in its legislative power to mitigate the negative aspects of those experiences safely and sensibly.

The fact of the matter is that backing pharmacists boosts our healthcare system, which is exactly what this bill does. Health is one of those bread-and-butter issues that a Labor government will always deliver on. We are after all the party that on a federal level brought in Australia’s Medicare. The Andrews Labor government is no exception to this rule. We have done extensive work in supporting and improving the Victorian health system by introducing innovative new approaches to the way Victorians receive health care. We are making treatment more accessible and alleviating pressures on our existing hospitals and clinics.

By allowing pharmacists the power to deliver more medications, two things will happen. Patients seeking prescriptions will no longer have to go through the hoops of renewing prescriptions when they require medication. This will be particularly impactful on Victorians who are not in a position to seek private health care and must go to the bulk-billing clinics, which often have much longer waitlists. This leads on to the second effect that this pilot will have on the health system. This pilot will have a positive impact on the strain that health services are experiencing right now. Our frontline workers are the backbone of our community, and for this reason every effort should be made to decrease the size of their workload.

Additionally, community pharmacists will be authorised to complete other services that previously in Victoria only GPs were able to deliver. This includes several different services. Wider access to these services through pharmacists will greatly ease the strain on our health care providers at this time. For example, community pharmacists with general registration qualifications will now be able to administer a wide range of vaccines, including both health and travel vaccines. This is technically an expansion of the already successful pharmacist-administered vaccination program. The amendments made by this bill will allow community pharmacists to deliver travel vaccines in addition to the core health vaccines such as COVID-19 and influenza vaccines that they already are authorised to administer. This is another measure in the bill that eases the strain on GPs to promote accessibility for patients. This will also lead to several other beneficial outcomes for Victorians – cheaper health care for a start – by eliminating the steps that the individual must take before purchasing their actual medication. Safeguards are put in place to ensure that the new method of acquiring a prescription is not more expensive than a normal bulk-billed GP visit. Additionally, overlapping medications that are affected by this authorisation of pharmacists and those affected by the pharmaceutical benefits scheme are in fact still covered by the Commonwealth government scheme. This is about improving accessibility for those seeking medications, not locking them out through pricing. ‘Community pharmacist’ is a very appropriate way to label this new role, as they are able to support the community and the members of the community medically when doctors are unable to do so, at the same rate of efficiency. The existence of such pharmacists will greatly decrease the financial squeeze that families can feel when they seek medical care.

The pilot program absolutely does not mean that the price of medicines will go up. Victorians will not be spending more than they would be when going to their GP. As of May this year there were 1453 community pharmacies across Victoria. This means that there are over 8300 pharmacists in Victoria with a general registration. That is all these pharmacists need – general registration and an untapped workforce of competent professionals. There are similar pilot programs that have been implemented in other jurisdictions, and they all show promising results for a solution to many of the problems that face many health systems.

We know there are similar programs implemented in domestic jurisdictions and internationally. Both Queensland and New South Wales have given pharmacists the power to treat less complicated cases or certain conditions, like UTIs, which, left untreated, may develop dangerously and in a manner that poses a serious threat to a patient, and difficult conditions to navigate the health system with. Queensland established the two-year trial in 2020 of a structured pilot program allowing pharmacists to prescribe medications to address UTIs which, since its conclusion and success, has been adopted as a permanent policy. It continues to produce results for people in Queensland needing treatment. Similarly, New South Wales is in the process of implementing a similar policy with similar structural regulations to provide specific trained pharmacists the power to prescribe certain medications for specific conditions. The Andrews Labor government hopes to learn from these examples by introducing the successful practice of prescribing pharmacists, taking notes from the strict regulation of those two northern states so that the rollout of our own pilot program will be as safe as possible whilst ensuring the flexibility inherent in the making of an effective program.

Prescribing pharmacists are not a new concept by any means. They have been a common fixture in the health system in New Zealand, the United Kingdom and Canada for over a decade and have proved to be very effective in decreasing the strain on their hospitals, clinics and other places of healthcare delivery. Additionally, in implementing the Victorian iteration of prescribing community pharmacists, in-house prescriptions will be subsidised by the Victorian government, meaning that all affected medications will be the same price as they are under the pharmaceutical benefits scheme. This is because we believe that it is essential that a government ensure that all its constituents are able to access necessary health care. This is achieved by removing barriers for people seeking health care and making it more accessible.

On the topic of accessibility, one of the bigger problems that health systems face is the very literal question of space. Geography can often determine your health and your health care that you are able to receive. This bill addresses that by making a concerted effort to implement community pharmacists in rural, regional and remote areas. Whilst it is an issue that not many of my constituents face, I understand, and I am sure everyone on the other side of the chamber does too, that seeking health care when you are an hour’s drive from the nearest GP or hospital can be incredibly difficult and sometimes dangerous. This is addressed by ensuring that regional pharmacists will have the same ability to prescribe as those in metropolitan areas. This will be a huge win for regional Victorians and improve their wellbeing and health.

The pilot has been designed and will continue to take on the recommendations from several expert groups and stakeholder representatives. This is to ensure that, through the extensive expert and stakeholder engagement, the pilot will in fact be the best possible version it can be before being rolled out. The design has been informed by the community pharmacist statewide pilot clinical reference group. The pilot’s clinical reference group has contributed greatly to the design of the pilot, ensuring that clinicians who are experts in their respective fields of medicine may contribute critiques and improvements to the model to ensure that we seek the best possible designed version of pharmacist-delivered prescriptions for the Victorian people.

The pilot clinical reference group is chaired by Safer Care Victoria, which comprises professionals who come from a range of backgrounds and fields of expertise. The reference group received input from veterans of fields like community pharmacy, microbiology, pharmacology, general practice, women’s health, infectious diseases, antimicrobial stewardship, therapeutic guidelines, clinical safety and so on. These contributors were experienced clinicians, pharmacists, educators and safety experts alike and all accomplished in their fields to ensure that the design was also informed by direct stakeholders external to the clinical reference group by way of an advisory group. The advisory group is comprised of pharmacists, doctors, community members and other stakeholders. This ensures that those who will interact with the pilot on a day-to-day basis as part of their job or medical treatment have had a hand in suggesting what they believe is the design to deliver the best outcome for the health system and those who interact with it.

In cooperating with clinicians the Andrews Labor government has ensured that all medicines that pharmacists will be able to prescribe are in line with the current clinical regulations. This is to ensure that the pilot is delivered as safely as possible. In addition to this, other measures to promote include a mandatory training program that all participating pharmacists will have to complete. There are other conditions determined by the clinical reference group that participating pharmacists and community pharmacists will have to meet. Guidelines and protocols on who and what can be prescribed will be carefully and thoroughly explained to participating pharmacists during their training in their new roles. They will also be easily accessible to ensure that there is no breach of community pharmacist privileges if they are genuinely unaware of the regulation. The department has also consulted directly with the Pharmacy Board of Australia and the Australian Pharmacy Council.

So in summary, although to many it may seem like a small change in the grand scheme of health regulation, this will forever change the Victorian health system and will change how Victorians interact with their health care. Seeking treatment should be easy and accessible. You should not be locked out of seeking care because of how much money is in your bank account or where you live. Every Victorian deserves a health system that can do what matters. One of the key aspects of that is having a government that backs pharmacists. The Andrews Labor government is that government. We will support anybody that does what matters, and pharmacists and GPs – they do.

This bill also highlights one of the key parts of this year’s budget: backing women’s health. Many of the conditions that participating community pharmacists will now be able to treat and prescribe medications for overwhelmingly affect women and girls – conditions for too long that have been ignored or not believed. This will remove the barriers that women experience in the health sector and ultimately will create a fairer, more equal and healthier Victoria. Improvement in women’s health is also one of the key areas that will be assessed at the end of the 12-month pilot. I look forward to seeing the results of the 12-month pilot, and I commend the bill to the house.

Renee HEATH (Eastern Victoria) (11:20): I rise to speak on the Drugs, Poisons and Controlled Substances Amendment (Authorising Pharmacists) Bill 2023. The purpose of this bill is to amend the Drugs, Poisons and Controlled Substances Act 1981 to introduce new regulation powers to enable pharmacists to supply, dispense, administer, use or sell schedule 4 poison drugs without a prescription in certain circumstances. I completely accept and understand that our health system is under pressure. In Victoria there are over 85,000 people on the waiting list for elective surgery, and it is getting harder and harder to get a GP appointment, particularly in regional areas. Patients are often left waiting in emergency rooms for hours. Something does need to be done, but in doing so we cannot put patients’ safety at risk. I do not believe this is the answer. I received a range of community feedback. This has sometimes been called a ‘dangerous pharmacy experiment’. So I think if we are getting that feedback, then we have to ask ourselves: what can we do to make it safe? That is something that I would like to talk about today.

We are putting some pharmacists in a position where they are required to diagnose and treat potentially complex issues. I know the legislation says ‘uncomplicated urinary tract infections’, but like some other people have said in this place, including Dr Mansfield, sometimes things present as uncomplicated UTIs but can actually be a more complex issue. There is a big difference between GPs and pharmacists, and they work so well together, hand in glove, because they do have expertise in opposite areas. One is entirely private – they take a whole history, they get to know the whole patient ‍– and one is in a more retail environment and it is not as private. Pharmacists play an extremely important role in the safe dispensing of medicine. GPs play an important role in forming a diagnosis, not in a silo but in the context of a whole person. Health is a complex interplay between different areas, and as we know, health is not purely the absence of disease. The two professions, along with others, should go hand in glove with each other. We should not be creating a competitive environment.

Pharmacists have a critical role in medical safety, and it is one that is extremely well respected. I have concerns that we may be putting young pharmacists in a position where without proper training they are tasked with the diagnosis of potentially complex issues. It does carry risks. The first risk is that we get the diagnosis wrong. The answer is not always medication, and that is where we need to have those in-depth conversations where we can begin to assess what the best option is. The other issue is that diagnosis of UTIs can be highly variable. I think that in order to achieve the right diagnosis and the right treatment that really cannot be done in a retail environment.

There were some comments during the Queensland pilot from the AMA. They said:

It’s an example of the power of lobbyists to influence governments to the extent that they would put on a trial that many professional organisations are telling these governments would harm the health of their communities, and yet they are still doing it.

I do see a need for legislation like this, but there must be safeguards. I will go through my concerns one by one about the issues that are covered in this bill. The first one is the treatment of minor skin infections. There actually are considerations in this area around patient safety. Current practice is pharmacists can already treat minor skin infections. Already pharmacists can prescribe hydrosol, novasone, corticosteroids and antifungals. In the bill, which is only four pages long, it does not specify what we are extending this to, what we are widening the scope to. Patients often go and see GPs for a second opinion regarding skin rashes that they may have had treatment for from a pharmacist who had not had time to do proper testing. For instance, there have been many occasions that doctors have spoken to me about where patients have been given steroids to put on a secondarily infected wound. That has actually delayed and complicated the treatment of something that should be a simple issue. So with this legislation what extra drugs are we able to give when pharmacists are already allowed to prescribe some drugs already? The bill does not outline what the further scope of this will be.

The second issue that is covered in this bill is uncomplicated UTIs. I have written a little bit on this, because I think that this is a bit of an issue. Dr Read in the other place spoke about overprescribing antibiotics and how that can increase the risk of antibiotic resistance. Patients who present with urinary discomfort do not always have UTIs, and these pharmacists do not have the right, not that I can see in this bill, to send for pathological testing. I find it really strange that there is somebody that is able to treat a condition but their licence does not allow them to refer for testing for that condition. That is a really strange situation that we find ourselves in.

Also, as I am sure many of you are aware, in 2019 Harvard University published a paper that said that antibiotic-resistant UTIs are on the rise. This is hugely worrying. This poses a public health risk. We need to be very, very careful – and I say ‘we’; I am not a GP – when we are prescribing antibiotics that we do it with a lot of restraint and a lot of consideration, because antibiotic resistance is a public health risk. We need to join the fight against antibiotic resistance. I spoke to a GP just yesterday who said she will not give or very rarely will give antibiotics for ear infections. And that is because she understands that this patient that she is seeing is in pain, they are going through something, but the risk of that measured against the risk of antibiotic resistance on a bigger scale is something that needs to be balanced up. So giving pharmacists the ability to just write out a script for this without proper consultation in the midst of an environment where antibiotic resistant UTIs are on the rise, to me, poses a risk. I believe that allowing over-the-counter antibiotics is not something we should be doing lightly, and we have to make sure that it is well regulated.

Dr Mansfield – it is funny I am mentioning my Greens colleagues – also mentioned record keeping. This is something that we cannot assess properly. There is a difference between GPs and there is a difference between pharmacists, and they need to be balanced together. So I think that the bill is admirable, but I believe that there are holes in this legislation that, if they are not fixed, can lead to poorer outcomes for patients.

The third area of course is the reissuing of the oral contraceptive pill for women. This seems like one that is the most straightforward; however, I do not think it is. There are different lifestyle factors that pose a risk when you are on the pill, such as obesity, smoking and migraines. If you have those three issues or one of those three, your risk of stroke actually is heightened. You can develop those at any time, and this is why it is important to continually have feedback with your GP, because they are the experts in this area who can monitor this. So the OCP can have severe side effects, and sometimes it requires a bit of monitoring and a bit of adaption, and this is something that is very important. It is not one size fits all. A GP who is a good friend of mine in the Gippsland area, Dr Nelson, said as well that during their clinical practice each and every OCP script appointment has been an opportunity for screening for disease and many other aspects of patient safety. They are concerned that these amendments will reduce their ability to safely care for their patients. There are so many different things that people come and talk about when they are having their follow-up appointment with the oral contraceptive pill. One of them is also intimate partner violence. This is a fantastic opportunity for us to capture and protect women. So what is the time line? When does this expire? Are you allowed to just keep getting the oral contraceptive pill year after year after year? If that is the case, I think that is dangerous. I think there are some serious safety concerns, because things change in our lifestyles. We can develop migraines, we can start smoking, we can put on weight – these things happen. It happens all the time, and our risk with medication changes with those things.

For many female patients when they go back for their follow-up check to get their script filled it is an opportunity for the GP to figure out if they are taking their medication accurately and adequately, to discuss STIs and to minimise the risk of that, to minimise the emergency use of contraception, to educate women on sexual and reproductive health and also to check for side effects. These are things that we have to really keep in consideration. They will not be able to be done just, like Dr Mansfield said, with a glass screen in a busy retail setting. So a huge issue of mine is: are we still able to monitor women that are coming in and assess whether they are in a good relationship, a healthy relationship? These are conversations for which there is wonderful opportunity to take place when you come for your follow-up. I am not against repeat prescriptions, I am for them, but we cannot cut out doctors and health professionals entirely without having severe safety risks.

So these are the questions I have: how will harm be minimised and how will stroke prevention and screening be carried out without GP monitoring? Another question I have is: is there going to be a register of how often women access this medication? If not, what measures will be put in place to ensure that women are not buying extra OCP medication for people that may be vulnerable and have not been properly assessed? And are we having thorough health checks, which is extremely important in this area?

While I have got only a couple of minutes left, there are two other issues I would like to quickly raise. One is insurance and liability. GPs pay a much higher premium due to the added risks of their job. They are consistently working with very complex cases. There are lots of moving parts in health, and their job is to sum it all up to make sure that a particular medication is safe. Because of that they pay higher premiums because there is a higher risk of misdiagnosis and a higher risk of mistreatment, so will pharmacists have to take on higher premiums to cover the higher risk that this scope will open up for them? That is something that we have got to consider. Also, when the bill talks about the prescription of schedule 4 drugs it is very broad. It does not say which ones they are, particularly. So what will this bill include? What will the scope of this be? What are the specified conditions? In the document in the Parliament that we have got here in front of us it states that schedule 4 drugs may be prescribed in the treatment of ‘uncomplicated UTIs’. This is an extremely vague term. How will that be determined? Often patients present with these conditions – and, by the way, something that presents as a UTI could be an STI, could be a dermatological condition, could be a neurological disorder and could be diabetes – so is there the ability for those patients to then be referred for testing to find out exactly what they have?

So they are my concerns. In theory and in principle I support the bill, because we do need to take pressure off the healthcare system, but in my opinion there have to be a whole lot of safeguards and registers and we need to make sure that the training is adequate to address the risks as well.

David ETTERSHANK (Western Metropolitan) (11:34): I rise to make a brief contribution on the Drugs, Poisons and Controlled Substances Amendment (Authorising Pharmacists) Bill 2023. The bill amends the act to establish a 12-month community pharmacist statewide pilot program, authorising pharmacists to dispense, use, administer, supply and sell certain schedule 4 drugs without a prescription, including oral contraceptives, travel vaccines, medicines for urinary tract infections (UTIs) and minor skin conditions. The pilot will be evaluated by an advisory committee after the 12-month program, and if successful, pharmacists will continue to provide this service into the future. Legalise Cannabis Victoria is happy to support this bill.

The program should make it easier for Victorians to access high-volume, low-risk primary care. It will relieve pressure on GPs and increase accessibility, particularly in remote and regional areas, where we know people often wait a considerable time to see a doctor. It will allow those GPs to focus on more complex needs patients. It will be particularly welcomed by women. After an initial consultation with a doctor women will be able to obtain oral contraceptives without having to see a doctor each time a prescription runs out. As my colleague Ms Payne will expand upon, women trying to obtain oral contraceptives or medication to treat urinary tract infections – a very common condition for women – need to be able to access these treatments as quickly as possible with minimal inconvenience.

Similar programs have already been implemented in other jurisdictions, including the United Kingdom and Canada. Closer to home, the urinary tract infection community pharmacy service pilot was completed in Queensland in 2022. An evaluation of that program by Professor Lisa Nissen at the Queensland University of Technology concluded that the program delivered safe and appropriate care that aligns to clinical protocols and that pharmacists have the appropriate skills, competencies and training to manage the treatment of uncomplicated UTIs in the community pharmacy setting. The program has been accepted, and Queensland is about to begin another community pharmacy pilot for a wider range of common health conditions. New South Wales is conducting a similar trial for pharmacies to provide UTI treatments and oral contraception without prescriptions, and South Australia has an inquiry into accessing UTI treatments based on the Queensland model. The scheme will increase access to low-risk medications and reduce costs for consumers, while going some way to reducing the burden on the health system. We commend the bill to the chamber.

Michael GALEA (South-Eastern Metropolitan) (11:37): I rise to speak, like Mr Ettershank, in favour of the Drugs, Poisons and Controlled Substances Amendment (Authorising Pharmacists) Bill 2023. This is a bill which helps to deliver on the Andrews Labor government’s commitments made last year, and it is an important step forward. It is one part of a broader suite of measures. We have spoken a lot about health and various initiatives over the past few sitting weeks. I had the privilege of touching upon some of the other health reforms that we are making in this chamber just yesterday, and this is one critical and very useful part of those as well.

The community pharmacist statewide pilot – or CPSP – delivers on one of our election commitments and is also good policy. This bill will not establish the pilot program specifically but will establish the necessary mechanisms for creating legal authorisations for pharmacists to participate in the pilot. That makes the amendments in this bill vital for the operation of the community pharmacist statewide pilot program. The bill will also establish the necessary foundation for the establishment of the pilot. Further work will be undertaken to create the detailed design for the pilot program and how it will be implemented, with stakeholder participation to inform that design, particularly regarding the project’s governance.

This government is investing $20 million to deliver this 12-month pilot program. The investment will enable us to expand the role of community pharmacists in a targeted and logical fashion. The benefits to people across Victoria of having greater access to affordable primary health care will speak for themselves long before this 12-month pilot is completed.

The amendments this bill makes to the Drugs, Poisons and Controlled Substances Act 1981 will enable the creation of regulatory powers, allowing pharmacists to supply specified schedule 4 medicines without a prescription. This is key for the pilot, as the mechanism enables the Secretary of the Department of Health to issue authorisation for pharmacists under the pilot to provide medicine for the treatment of mild skin conditions, antibiotics for uncomplicated urinary tract infections (UTIs) and the continued supply of the oral contraceptive pill without a prescription.

The amendments in this bill enable what we call structured prescribing by pharmacists, enabling those pharmacists who have undertaken the appropriate additional training to provide medicine in compliance with the established clinical protocols. The CPSP, the community pharmacist statewide pilot, reflects the need and desire of local communities to have more options and access to primary health care. It acknowledges the demand on GPs and hospitals to meet those communities’ needs. This 12-month pilot program responds to these factors, expanding pharmacists’ roles in their communities in a sensible and responsible manner. Allowing pharmacists to operate under the pilot and have greater autonomy to support their local communities will remove some of the barriers for some members of our community to access the vital health care that they need, such as distance from home, cost and complexity.

This expansion of the role of community pharmacists will also ease the pressure on our healthcare system, on our GPs and on our hospitals. As many members will know, the resourcing of general practitioners and the governance of that is a federal government responsibility. Nevertheless this is a state government that has not at all been backwards in coming forwards in delivering what is needed for Victorians. In the face of repeated underfunding of programs such as Medicare and bulk-billing by the former federal government, we have stepped forward and invested in, for example, priority primary care centres right across the state, including the one in Narre Warren in my region of the South-East, which is already delivering benefits for my constituents in getting quick, accessible health care close to home. I also of course spoke yesterday about our wellbeing and mental health clinics, which are already bringing those mental health services closer. We are very much looking forward to the opening of the Narre Warren mental health and wellbeing local, which has been funded and announced in this year’s budget, as well as future planning works for further ones in Officer and in Cranbourne. Allowing pharmacists to operate under the pilot and have greater ability to support their communities will remove some of these barriers, as I have said, and when the pilot is established it will also help make health care more accessible for the community and help GPs and hospitals in high demand, allowing them to see more people who urgently need to see them in those emergency rooms and in those general practice offices.

The community pharmacist statewide pilot, the CPSP, will align with the approach already established in the Queensland UTI pilot and the New South Wales pharmacy trial. So this is nothing particularly new or outrageous or radical, and this follows the examples of what those two states have done. Queensland’s two-year pilot program was established specifically for uncomplicated UTIs, which will be covered in a similar manner by Victoria’s CPSP. The pilot in Queensland has already clearly shown the positive impact of the program, especially and most importantly how it can improve access to safe primary health care. The fact that the ability for pharmacists to provide medicine for uncomplicated UTIs is now a permanent fixture in Queensland speaks to the success of that pilot. I also note from my colleague Mr Ettershank’s contribution that Queensland are now undertaking a further trial in a similar vein based on the success of their first one. So I hope these examples provide some comfort. I listened with interest to my colleague Dr Heath’s speech as well, and I hope these examples can also provide some comfort to those members still grappling with some of the finer points of this detail and are persuasive in showing that this is something that will be very effective.

We have a clear picture of a completed pilot program in two states as evidence of these benefits. In New South Wales there is a similar statewide trial that enables pharmacists to supply treatments for uncomplicated UTIs in women, just like in Queensland, and also for the continuing prescription of low-risk oral contraceptives and medication. Queensland has already made its trial permanent, and New South Wales is conducting a similar trial with the same goal. Overseas we can see that in New Zealand access to oral contraceptives provided by pharmacists was in place in 2017, and there is already a long-established practice of pharmacists prescribing select medicines in that country, as well as in Canada and in the United Kingdom. So as much as we would like to take the credit for inventing this concept, there are already so many jurisdictions around the world with similar practices in place, as well as other jurisdictions here in Australia that have undertaken or are undertaking trials on a similar basis.

This is the right time to do this. Why have numerous other jurisdictions undertaken to expand the role of pharmacists – because it is a commonsense measure to relieve pressure on GPs and hospitals and because it will benefit communities and individuals, giving them better access to affordable primary health care. This is of particular benefit to remote and regional communities, and it has also been demonstrated by the experiences of New South Wales, Queensland, New Zealand and the United Kingdom. I have little doubt that when this pilot is underway in Victoria we will see those same benefits flow through, which will prove the effectiveness of taking these measures.

Beyond achieving the overarching benefits in terms of access to primary health care for the community generally, I would also like to touch on what are likely to be several specific positive results of having pharmacists operating under the pilot. Visiting a local pharmacist to get the medicine you need will save families money. It will mean that consumers can access the services approved under the pilot program by a trained pharmacist without worrying about paying more than what they would have done if they had instead sought that service from a bulk-billing GP. It will also enable people not to have to accept paying more to visit a non-bulk-billing GP or paying for a more extensive commute if a bulk-billing GP is not locally accessible. Again, the number of bulk-billing GPs has gone down dramatically, and I do welcome the federal government’s intervention this year to provide more bulk-billing support. I know that there is certainly a lot more work to be done, and it is going to take a long time to fix nine years of damage to and neglect of our Medicare system. I certainly hope that the government at the federal level will continue that program. I am sure it will not be resting on its laurels.

This pilot will enable people not to have to accept paying more to visit a non-bulk-billing GP. No-one, as I said, should have to choose between accessing the care they need and the work that they need to do to earn a living. Whether it be because a bulk-billing GP has a restrictive schedule, is too far away or unavailable for other work reasons, Victorians will save money by being able to see pharmacists for approved services under the CPSP. They will not have to pay more than they would if they were seeing a bulk-billing GP.

Considering the treatments that the pilot will cover, women and girls in particular will benefit significantly from this improved access to primary health care. This benefit aligns with other recent investments made by the Andrews Labor government. Free pads and tampons are now available in every government school in Victoria. That $20.7 million nation-leading initiative will help students across Victoria’s more than 1500 government schools. The 2023–24 state budget also focused on various other women’s health initiatives and investments, and one that I have also repeatedly drawn attention to in this place is the $58 million for 20 comprehensive women’s health clinics, including the one in my region, at Casey Hospital, which is going to be of significant benefit to my community.

Another point I would also mention is about being able to go to a community pharmacist. Community pharmacies are an easily accessible setting for many people, more so than a hospital, and even a local GP for some people can still be intimidating. Some people with low-risk healthcare needs may feel hesitant to make an appointment with a GP if they are anxious about the perceived formality of such a process, or perhaps they may feel that they do not want to be a bother. There can be several reasons that could lead to someone ignoring their primary health care, putting it off longer than they should. Being able to visit a pharmacist sooner is a great alternative that will help those people overcome that hesitation about taking the first step.

There is also something to be said about the social accessibility of a pharmacy. People go there to pick up personal hygiene products, mouthguards and sunscreen, to get their flu and childhood vaccines – and thank you to the Amcal in Beaconsfield for my flu shot this year, which given what is going around at the moment, I am hoping will keep me in good stead for some time yet – and also to pick up their prescriptions. People are very familiar and comfortable with visiting their local pharmacist. Pharmacists in health care already manage a range of health conditions and regularly refer their patients and clients to a doctor when required.

The benefits of this pilot program should be clear. I will reiterate some specifics about how this pilot program will be established. Pharmacists participating in the program can supply approved medicines following established protocols for the continued supply of selected oral contraceptives for women, treatments for mild skin conditions and antibiotics for uncomplicated urinary tract infections in women. Pharmacist immunisers who participate in the pilot program will similarly be able to administer additional travel and other public health vaccines, including hepatitis A and B, typhoid and polio to people five years of age and older.

The 8324 pharmacists with general registration will be eligible to participate in the program on an opt-in basis. They will of course be expected to meet the relevant conditions to become part of the pilot program. When dealing with schedule 4 medicines, safety and of course efficacy are very important, which is why a pilot clinical reference group will be established to provide expert input and guidance into the creation of the pilot’s design. This reference group will be made up of expert clinicians, pharmacists, educators and safety experts and will be chaired by Safer Care Victoria. Community consultation will occur through the input of an advisory group of key stakeholders, including pharmacists, doctors, consumers and other members of the community. The pilot design will set out conditions for participating in the pilot and training programs that will be mandatory for pharmacists before providing services in line with the pilot program. The design will also establish guidance and protocols for treatment eligibility and doctor referral requirements as well. As part of the eventual design of this pilot there will also be a period for an evaluation of the 12-month program to be completed. This will assess the improvements towards consumer access, the effect on the broader health system in easing pressure and the safety of the pilot program. This evaluation will also inform how we move to that next step beyond the pilot, how we implement any permanent changes to how primary health care is delivered and what role community pharmacists will play moving forward from there.

The community pharmacists pilot is essential in exploring how we can improve access to primary medical services. Over the 12 months of this pilot program communities I expect will have improved, affordable and more immediate access to low-risk primary health care for specific conditions. Accessing these services from pharmacists will help ease pressure on GPs and hospitals at a critical time, especially in regional areas. The amendments in this bill will allow for the establishment of mechanisms to authorise pharmacists to prescribe specific schedule 4 drugs, making it critical for the pilot to operate. Once it is concluded the evaluation’s findings will shape future policy settings regarding the role of pharmacists and pharmacies in Victoria. The sooner we start, the sooner we can look towards how we can improve all Victorians’ access to safe primary health care. I commend the bill to the house.

Rachel PAYNE (South-Eastern Metropolitan) (11:52): I rise to speak to the Drugs, Poisons and Controlled Substances Amendment (Authorising Pharmacists) Bill 2023. My colleague David Ettershank has already provided an overview of this bill and Legalise Cannabis’s position, so I will not repeat the points that he has eloquently delivered. Instead I speak as someone with lived experience of the importance of increased accessed to oral contraceptives and medicines for urinary tract infections, as provided for in this bill. As someone who has suffered not one but two kidney infections based on the fact that I had a UTI and could not get in to see a doctor for two to three days, for me it is a no-brainer when you know your symptoms, you know what has caused your infection and you need your medication. It makes complete and utter sense to me that you can communicate that to a professional such as your pharmacist and have that access granted. In 2017–18 kidney infections and UTIs were the second most common cause of potentially preventable hospitalisations in Australia. They also accounted for 1.2 per cent of all problems managed by GP consultations. Early diagnosis and appropriate antibiotic treatment for UTIs are so important to help reduce the need for hospitalisations and patient morbidity.

In respect to oral contraceptives, these are one of the most commonly used contraceptives in Australia. Timely and accessible access to contraception is imperative for greater autonomy and improved health, and it decreases stigma. Stakeholders I have spoken to agree that this bill will reduce the burdens on Victorians to accessing sexual health care. Trying to get into a GP is hard enough. Less bulk-billing and less acceptance of new patients mean that we are all struggling to get in to see a doctor. Being forced to wait days for an appointment when you know that you only need your medication for your STI or to get a new script for oral contraceptives can be incredibly frustrating, leaving you in unmanageable pain and unnecessary pain. We should make health care in our state as accessible as possible. That includes sexual health care, and I commend the government on the work that this bill does support. I also reflect on the fact that in both Queensland and New South Wales there have been similar trials that have been conducted successfully – and a UTI in Queensland is the same as a UTI in Victoria.

Jacinta ERMACORA (Western Victoria) (11:55): This bill amends the act to introduce new regulatory powers to allow pharmacists to supply, dispense, administer, use or sell schedule 4 poisons without prescription in certain circumstances. Schedule 4 poisons are prescription-only medicines such as antibiotics and strong analgesics and do not include schedule 8 poisons, which are classified as controlled drugs with strict legislative controls. The aim of this bill therefore is to simplify and improve access to high-volume, low-risk primary care and to reduce the burden of this work on general practitioners. This in turn will allow them to focus on providing more complex care.

Consultation on the bill has been limited because this bill creates a 12-month pilot within which consultation will occur. Further design will be informed by comprehensive stakeholder participation. This bill automatically creates a dynamic real-time trial for engagement over a 12-month period, fulfilling our 2022 election commitment to back pharmacists to boost our health system. By creating new regulatory powers the bill is the first step in establishing the legal and regulatory framework for community pharmacists to supply medicines within the scope of the pilot. The community pharmacist statewide pilot, as it will be known, will make it more straightforward and cost-effective for Victorians to get the health care they need quicker and closer to home. Put simply, the pilot will enable community pharmacists to treat mild skin conditions and uncomplicated urinary tract infections (UTIs), reissue supply of oral contraceptives and administer more travel and public health vaccines, as they are already doing.

The pilot is based on a founding principle of good clinical governance. The government proposes to run this trial with community pharmacists enabled to undertake structured prescribing. This model is currently being used successfully in the New South Wales pharmacy trial and the Queensland urinary tract infections pilot. Structured prescribing is where prescribing authorisation is tied to particular conditions – for example, completion of specified training and compliance with established clinical protocols. I can alleviate Dr Heath’s concern about young pharmacists not being trained; it is not possible under these conditions for a pharmacist to do this without completing the required training.

These commonsense reforms seek to make practical changes to our medical system by focusing on four conditions: access to the oral contraceptive pill, treatments for some mild skin conditions, antibiotics for some mild UTI conditions and the administration of certain travel vaccines by pharmacist immunisers participating in the pilot following approved training. Each of these conditions are important due to their commonality for many in our society, and throughout the trial the Department of Health will listen to the views and experiences of all involved.

Business interrupted pursuant to standing orders.