Given the absence of any demonstrable possible patient or system benefits, how else could this ever have seen the light of day?
If you’re wondering, given the absence of any demonstrable possible patient or system benefits, how the Queensland pharmacy prescribing trial could ever have even seen the light of day, then think ‘Game of Mates’.
Game of Mates is a book by two Queensland economists that outlines how deeply connected networks are formed between individuals in government, the public service and key persons within powerful and rich industry sectors.
These networks behave in a manner similar to sophisticated criminal organisations (the authors use the Mafia as one example) to extract favours from politicians and public servants that divert wealth and power.
Perhaps unsurprisingly, authors Cameron Murray and Paul Frijters, actually single out the Pharmacy Guild in their book, as a major example of an industry sector and group of wealthy individuals that are ardent practitioners of the Game of Mates.
“The multimillion-dollar windfalls to … the 4,000 pharmacy owners he [the then Guild President] represents are a ‘grey’ gift that comes at a cost to the most vulnerable in society, who pay through higher health expenses,” say Murray and Frijters.
A “grey gift” is a government ruling, policy or piece of legislation that costs nothing but bestows on particular groups of individuals within society the significant ability to create or maintain wealth into the future.
Usually, the body or individuals that stand to gain from a grey gift will argue that although they stand to gain from it, their investment in the sector will result in overall good for a community. But it rarely does. Mostly, those receiving grey gifts are provided with an ability to create inordinate amounts of wealth, at significant cost to taxpayers.
A common example of a grey gift is land rezoning by local government. Here, a developer is positioned as an investor who will invest in and develop rezoned land for the greater good of a community. But developers rarely pay anything for the significant additional value that a government body can create by rezoning land. The vast majority of the value in land rezoning is lost to the public and ceded to the developer as a grey gift. That’s why you see a lot of developers on local councils.
In pharmacy, a grey gift that keeps giving is the Community Pharmacy Agreement with the federal government.
This agreement, adjusted every five years, artificially holds in place licensing controls on pharmacy ownership and pharmacy location restrictions that act to protect existing pharmacists from competition.
The government and the pharmacy lobby argue that, without these restrictions, pharmacists would not be able to survive and their value as health professionals would be lost to the community. But this argument has no evidence base to it and it’s never been tested. The decision by our federal government to keep granting protection to pharmacists is entirely discretionary.
Most of the value of this discretionary government protection of pharmacy accrues to pharmacists – not to the public or patients. It’s an unfair deal, allowed to persist by both major political parties, who choose to give away taxpayer money in order to keep what they perceive as a politically powerful interest group off their backs.
The Queensland pharmacy prescribing trial ticks every box of the sort of grey gift you see in a classic Game of Mates dynamic.
- A free gift of enormous value to an interest group at taxpayer expense
The trial, if successful, would confer a vast amount of commercial opportunity and value into the future for retail pharmacy but provide very little to no value to the public (patients).
Patients will end up with more cost, less access to care and have their existing care fragmented. Value will shift from the patient and taxpayer directly to the pharmacy sector.
If pharmacists end up being granted the rights to prescribe in the manner proposed in this trial, the commercial gain will be significant over time:
- It would probably shift MBS payments from the GP sector to pharmacy over time but, regardless, pharmacists would secure a large new income stream
- Pharmacists, as both specifiers of drugs now, as well as the sellers, would be in a position to profiteer by specifying the most profitable prescribing outcome for their business
- It would provide significant new upsell opportunity for other non-prescription products by a pharmacist
- It would increase overall foot traffic into pharmacy, which for retail businesses is a vital revenue-generating KPI
- No societal or taxpayer gain from the gift
Patients won’t benefit from pharmacist prescribing, as proposed in this trial, as it:
- Increases the cost of healthcare to them quite significantly as the drugs will not be subsidised by the PBS and the consultation won’t be subsidised by Medicare
- Will fragment a patient’s care by disintermediating general practice in the management of significant health conditions for a lot of patients
- Will decrease access to the most appropriate and effective care available via the two points above
Taxpayers overall won’t benefit because additional money will need to be spent by the Queensland government and patients that will be in addition to what is already being spent by the federal government on achieving the same outcomes. Potentially one day, MBS money will be shifted from general practice payments to pharmacy via additional federal lobbying by the pharmacy sector, creating a further rift in care between pharmacy and general practice.
- No independently verified evidence for the gift giving
There is no global or local evidence to justify even trialling pharmacy prescribing on the grounds that it increases patient access and outcomes. Recent literature reviews on the subject find that even in countries where pharmacy prescribing is allowed, the evidence is not clear on whether it improves patient outcomes.
Supporters of the trial will argue that this what the trial is for, but the trial is not being run by independent researchers looking to compare the real cost and effectiveness of care; it is being run by a government and lobby groups with an agenda to shift government money from general practice into pharmacy. The outcome is pre-determined as the objective is not to improve patient care (that is actually stipulated in the design revealed in leaked documents of this trial), but to improve the commercial lot of retail pharmacists (this, of course, is not stipulated – they call it “working to full scope”).
- A lot of easily identifiable conflict of interest
There is significant smoke in terms of potential conflict between Queensland government personnel involved in deciding that Queensland needs to extend the scope of their pharmacists to prescribing, and key figures in the pharmacy lobby.
While this in itself is not proof of impropriety, the highly visible potential for conflict has not been addressed or even acknowledged by Queensland Health. Pharmacy lobby royalty – the likes of Kos Sclavos, Trent Twomey and Terry White – have been very close to senior politicians and public servants in the Queensland government for many years now.
- Significant political donation activity
Data from the Australian Electoral Commission released this week reveals that the Pharmacy Guild is as close as you can get to the fourth-biggest political donor (they actually came in sixth but the gap between fourth and sixth is minimal) in the country, having spent $295,149 in the past year, most of it on the Coalition. Nearly 30% of the total was given to the two main Queensland political parties. The Queensland branch of the ALP received 40% of the Guild’s entire donations to the Labor party.
Is it coincidence that Queensland, which is pushing the envelope the most in terms of expanding retail pharmacy upstream into the work of general practice, received the lion share of the Guild’s political largesse?
Murray and Frijters argue that organisations practising consistent and high-relative-value political donations are a red flag for the Game of Mates. They argue that donations aren’t about direct influence, as they are in relative terms tiny compared with the value of a grey gift, but are important to signal to politicians that an organisation wants to play the Game of Mates. They liken donations to tattoos that identify a gang member as belonging to a particular gang.
The Pharmacy Guild is one of the most consistent and highest-paying donor organisations to political parties – state and federal – in the history of keeping donation records.
- Mates being granted favours once they leave politics
An important marker of the Game, say Murray and Frijters, is what happens to key public servants and politicians after their careers in government. Mining and defence are particularly obvious recent examples of senior politicians securing lucrative roles with organisations with powerful groups who once were lobbying for favours.
Below is a chart published by The Conversation that provides an example of the dynamic in action in the resources industry.
The dynamic is in play in healthcare. There are plenty of past politicians with health portfolios, and senior public servants in the Department of Health, who end up in high-paying jobs with consultants, corporates and even industry sector organisations.
A recent example is the current CEO of the Pharmaceutical Society of Australia (PSA), Mark Kinsela. Kinsela is highly connected in political and public service health circles, and is successful and smart. Most of his career prior to his appointment to the PSA has been spent with various public health departments and agencies.
Here is part of his own Linked In profile:
- Over twelve years’ experience in primary health care and aged care, including six years working in Government advisory in aged care, health system management, Pharmaceutical and health and hospital funding.
- Former Adviser to the Commonwealth Minister for Health.
- Extensive public health policy experience, most recently playing an integral role in developing the Commonwealth Government’s $3.7 billion aged care reform package.
Why doesn’t this trial identify patient objectives?
The Medical Republic put a very simple question to both the Pharmacy Guild and the Queensland department of health (DoH) in respect of what we think is the defining problem of the pharmacy prescribing trial:
Can they outline the specific patient outcomes and system objectives of the trial?
We ask this because even the Queensland Pharmacy Council, which has been controversial for its role in extending protection of pharmacy businesses in Queensland with its recent (2018) ownership and territory legislation, and its stated aim of seeking to extend the scope of pharmacists in the provision of community health, lists its major objectives as:
- improved [patient] accessibility,
- convenience and satisfaction for patients
- lower out-of-pocket costs for consumers and lower costs to the health care system
- better health outcomes for patients, and
- improved job satisfaction for health care workers.
None of these objectives, other perhaps than pharmacist job satisfaction, are achievable, based on the pharmacy prescribing trial outlined in the leaked documents of the proposal to Australian Doctor last week.
The Pharmacy Guild initially deflected our request to the Queensland DoH, and then when we specifically asked why it could not provide such basic and obviously important information, it refused to answer any further questions.
The Queensland DoH did answer the question as follows: “The aim of the pilot is to increase access to high-quality, integrated, and cost-effective primary health care services for North Queensland communities.”
At least it answered.
But it’s a nonsense answer to make us go away. The trial is proposing to:
- Charge patients private-billing fees for prescribed drugs (the MBS will not be paying)
- Charge a consult fee, for which it is unclear if the Queensland government is paying or not, but even if they are, that’s adding to the overall tax burden of Queenslanders
- Provide a pharmacist with an ability to change the prescription of a previous carer without reference to that carer or that carer’s medical notes, something that clearly does not meet the objective of “high quality” or integrated” care, as the Queensland DoH claim.
The Qld DoH pointed out to us that “in accordance with best practice, an independent external provider will be engaged to undertake a service evaluation of the pilot including examining accessibility, continuity, effectiveness, efficiency and sustainability, responsiveness, and safety”.?
This we assumed was an attempt to say that it is hands off in the decision making around the trial.
We then asked if it could provide an example of such a provider so we are able to gauge what degree of independence there might be in evaluating the trial. Its reply to this query was: “We have nothing further to add to our [previous] response.”
One way to read this response and their failure to address this most basic question: there is no actual independent external organisation evaluating this trial.
Oh, and go away … we’re sick of having to answer questions that go to the integrity of this trial in terms of actual patient benefit.
This trial is very clearly a grey gift from the Queensland government to the pharmacy sector.
A big theme in Game of Mates is how much discretion government departments have to make decisions such as this pharmacy trial without any scrutiny, or any requirement to answer to the public on questions like those we put to the Queensland DoH on just how independent the trial evaluators would be.
With grey gifts, often a government department is not answerable to anyone but itself and no one can do anything about it.
What step do we as a media group take after the Queensland DoH point blank tells us to go away, after not answering questions relevant to independently assessing the public good of a trial it is proposing to conduct?
An interesting characteristic of most grey gifts is that the gift is technically within the discretionary power of a department or government to grant. No laws or regulations are broken. And no one is required to answer tricky questions.
Queensland Health told us on Wednesday that it has formed a steering reference group to provide “strategic oversight and advice” for the pilot. This group includes the Royal Australian College of General Practitioners, the Australian Medical Association Queensland Branch, and the Australian College of Rural and Remote Medicine.
At this revelation you might be really starting to wonder what is going on.
We certainly are.
Especially when you consider that this leaked proposal was reported by Australian Doctor last Thursday, and when we got comment from the RACGP and AMA the next day it sounded like it was news to them – they certainly didn’t say “Yes, we hate it, but we’re on the advisory group so we can keep an eye on it”. Fast work by Queensland Health, getting them involved in something they have publicly slammed in just a few days.
Until we learnt this, we would have classified criticism of the RACGP and AMA presidents in this matter for not doing anything as pretty harsh, because really, there is nothing they can do.
All these doctor-based organisations have come out publicly swinging, saying the prescribing trial is a sham.
Why would they then endorse such a trial by agreeing to take part in it? (At the time of writing, the RACGP had confirmed to us that it wanted “a seat at the table”, but the other two hadn’t responded to our questions.)
Members should be angry about this.
The Queensland DoH is not answerable to anyone for this trial other than the Queensland government. We surmise that the AMA, RACGP and ACRRM, realising this, want some sort of inside loop on what is going on by agreeing to put up representatives for the trial.
But this is a big mistake.
The Queensland government won’t care what representatives from these doctors group say on this reference committee. It has entirely ignored every submission from these groups on the formation of the Queensland Pharmacy Council, which had a stated objective of pushing pharmacy prescribing into the future.
If we ever see a press release announcing that the trial is a success, it will surely feature some form of thanks for the participation of the AMA, ACRRM and the RACGP in the pilot. That every representative from these groups will have damned the project for what it is won’t be mentioned.
The AMA, ACRRM and the RACGP are bad at playing the Game.
It would be a far stronger statement for all the doctor-based groups to pull out now and explain in a joint statement to the public why they aren’t taking part.
Key federal funding bodies and health regulators, such as the MBS, Medicare, AHPRA and the Medical Board of Australia, have no power to stop the Queensland government from legislating that Queensland pharmacists can prescribe.
If the trial is used to green-light prescribing in Queensland, it will be a grey gift that has been years in planning and in the making. It will have involved an intricate network of individuals in government mixing it with powerful and influential pharmacy lobbyists in Queensland, over a long period of time.
If you’re able to get a major government health department to conduct a trial that even in its proposed design is expressly bad for the patient and the system, then you are very clearly a powerful force that has some serious networks of influence operating in your favour.
This trial was never going to be simple for less influential groups such as the RACGP, the AMA and ACRRM to unstitch. For one thing, this grey gift is being made at the state level in Queensland, and these doctor groups’ influence, what little they seem to have, is primarily at the federal level.
The public aren’t aware of what is going on at all here, as they aren’t of most of what goes on in all the Games of Mates being played out across mining, banking, transport, land development, infrastructure development and so on.
The public would probably not believe a media outlet if one told them precisely what was going on in Queensland with this pharmacy trial.
“Pharmacists doing deals with government which prioritise money over patient wellbeing?” They might believe that of politicians but they wouldn’t believe it of pharmacists.
This is partly why pharmacy is such a powerful lobby group. Their community brand of integrity is almost impenetrable.
There are a lot pharmacists who wouldn’t support what the Queensland government and its pharmacy lobby is attempting here, which is some irony.
More irony perhaps is the Queensland government’s announcement this week that it will investigate its own Crime and Corruption Commission (the only force truly independent of the government that is empowered to dissect deals like this that don’t make sense for the taxpayer).
Too outrageous to fly?
There is some talk that the idea of pharmacy prescribing in the manner proposed in this trial is simply too outrageous for the Queensland government to ever really get it over the line, given its very obvious flaws in terms of patient outcomes, safety and pharmacist conflict.
But this would be a dangerous position to adopt based on history, especially the history of the Queensland government in matters like this. Even recent history.
Another characteristic of Game of Mates, when played well, is that the network of favours and counter favours is so sophisticated and complex that it is nearly impossible to nail down any one transaction between groups or individuals and tag it as “corruption” that can be acted upon by an external body of review.
This pharmacy trial has this characteristic.
The formation of the Queensland Pharmacy Council five years ago, and the inner goings on between the pharmacy lobby and very senior people in the department of health in this state for many years, has seen so many different individuals involved, and passing through, that the pharmacy lobby could easily make an argument that there is no smoking gun in this situation. Indeed, the evolution of this trial is almost inter-generational in terms of some of the power brokers in the pharmacy lobby in Queensland.
This is part of the dynamic of Game of Mates.
It’s a long game of networks and influence. No one person does anything wrong. There are no loose or out of place single peices an external group can latch onto.
At any single point of time, there is almost always “nothing to see here”.
When a grey gift is given by a politician or public servant there is no direct recompense to that individual so on the surface it seems like they would have nothing to gain from the decision. Hence, the decision must be in the public interest in some way, goes the logic.
Where one party is an obvious winner in the imparting of a grey gift, there is invariably a lot of smoke and mirror explanation as to how the benefit of this winner results in even greater benefit to the taxpayer.
There’s a fair bit of that rubbish talk already from Queensland Health in trying to explain away this trial.
Replying to us that the trial objective is to provide “access to high-quality, integrated, and cost-effective primary health care services for North Queensland communities” is a great example of putting out a nonsense statement in the hope that people will just move on.
Nothing about the design of the trial points to objectives that Queensland Health outlines in this statement being realistically in play. But they say it anyway.
With grey gifts there is of course always a return favour down the line in the form of a position on a board, or a lucrative job post politics or public service; of course, offered only after any perceived or regulated term of conflict has passed.
For a good list of recent examples of this read the Conversation piece I took that graphic from: Revealed: the extent of job-swapping between public servants and fossil fuel lobbyists
The Game of Mates is not a game that Joe Public is able to play and in this situation Doctors Karen Price and Omar Khorshid are Joe Public. Their organisations have never had any real skin in the Game.
Members of these organisations who expect a much better lobbying performance from their organisations might be angry that they haven’t got what it takes to fight back against the pharmacy lobby. But they should at least be consoled that their organisation is not unscrupulous in how they are prepared to operate, as The Pharmacy Guild surely is.
If you examine how this trial eventually came about, from the formation of the pharmacy-friendly Queensland Council of Pharmacy more than five years ago – with an edict to not only continue to artificially protect the businesses of pharmacists through ownership and location legislation, but also to extend the scope of pharmacists’ work into prescribing, over many intervening years of lobbying from key pharmacy organisations, companies and individuals, including some who ended very high up as managers and administrators in the Queensland DoH – what would any truly independent outsider make of what has happened here?
It ticks every box in the Game of Mates.
For anyone who managed to read this far and are interested in reading Game of Mates, we are offering free copies (print or digital as you specify) to the first 20 GPs who fill out the request form below by 15 February.
