PN772

VICE PRESIDENT HATCHER: Ms Knowles.

PN773

MS KNOWLES: Yes. I call Katerina Malakozis.

PN774

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

PN775

MS MALAKOZIS: Katerina Maria Malakozis (address supplied).

<KATERINA MARIA MALAKOZIS, AFFIRMED�� [10.04 AM]

EXAMINATION-IN-CHIEF BY MS KNOWLES�� [10.04 AM]

PN776

VICE PRESIDENT HATCHER: All right. Ms Knowles.

PN777

MS KNOWLES: Ms Malakozis, have you prepared a statement for these proceedings?‑‑‑Yes, I have.

PN778

And is that statement which is 23 paragraphs long and six pages long?‑‑‑Yes, it is.

PN779

And are the contents of that statement true and correct?‑‑‑Yes, they are.

PN780

I tender that.

PN781

VICE PRESIDENT HATCHER: The statement of Katerina Malakozis dated 20 December 2017 will be marked exhibit 6.

EXHIBIT #6 STATEMENT OF KATERINA MALAKOZIS DATED 20/12/2017

PN782

MS KNOWLES: No further questions.

PN783

VICE PRESIDENT HATCHER: Mr Seck.

CROSS-EXAMINATION BY MR SECK�� [10.05 AM]

***�� KATERINA MARIA MALAKOZIS�� XN MS KNOWLES

***�� KATERINA MARIA MALAKOZIS�� XXN MR SECK

PN784

MR SECK: Thank you, your Honour.

PN785

Ms Malakozis, my name is Michael Seck. I am the barrister for the Pharmacy Guild of Australia. I am going to ask you some questions in cross-examination. Your statement says, Ms Malakozis, that you have been employed by the same employer, National Pharmacies, for 28 years. Is that so?‑‑‑Yes, that's correct.

PN786

But you have worked at various pharmacies which had been owned by National Pharmacies during that 28-year period?‑‑‑Yes. I have been the pharmacist in charge since 1993 and I have worked at various locations throughout South Australia in that role.

PN787

And you also, I gather, in working with National Pharmacies for that 28-year period been reasonably happy working there?‑‑‑Yes, I have been.

PN788

And you were recently involved in negotiating a new enterprise agreement as a bargaining representative on behalf of employees with National Pharmacies. Is that so?‑‑‑Yes, that's correct.

PN789

In paragraph 9 of your statement, you say that you are earning $48.51 per hour at the moment. Is that the rate contained in the new enterprise agreement of the pharmacist-in-charge position?‑‑‑Yes, it is.

PN790

And - - -?‑‑‑I'm sorry - one of the rates, correct, yes.

PN791

Yes. And when you say "one of the rates", I think the rates, as I understand it, differ, according to seniority. Is that right?‑‑‑They differ according to size of the store, number of staff, turnover; various means of measurement that the organisation uses.

PN792

Right. And in negotiating the agreement, you would have been aware of the rate that applied to the pharmacist-in-charge position under the Pharmacy Industry Award. IS that so?‑‑‑Yes.

PN793

And on my reading of what the current rates are, and tell me if you know or don't know this, it's about $29.45 an hour?‑‑‑Yes, that's correct.

PN794

So looking at it, what you have negotiated under the enterprise agreement is around $19 per hour higher than what is contained in the award?‑‑‑Yes. It's an agreement that we have been negotiating for quite a number of cycles.

***�� KATERINA MARIA MALAKOZIS�� XXN MR SECK

PN795

Yes?‑‑‑So this is probably the fourth agreement that I have been involved with and we have continued to negotiate marginally what we have in the previous agreement and we have just tried to marginally increase it if possible where possible.

PN796

And where you say you have marginally increased it "if possible where possible", I gather from that it has been possible to marginally increase the wages each round of enterprise bargaining negotiations that have taken place?‑‑‑Prior to the current agreement, we may have been able to gain a one per cent, one and a half per cent increase. This current agreement was not that simple. So that's why I said "if possible". We were not able to get any great increase at all.

PN797

Was the increase uniform across all of the pharmacist classifications in terms of percentage, or did it differ?‑‑‑The increase, if I remember correctly, would have been the same over all pharmacists. So it would have been the same percentage increase.

PN798

Right. I have read the most recent enterprise agreement applying to National Pharmacies, and you have signed that agreement as a bargaining representative. Is that so?‑‑‑Yes, that is.

PN799

And I noticed that APESMA also signed the agreement separately as the relevant union. Does that accord with your recollection?‑‑‑Yes. They were involved in the negotiation.

PN800

Now, just so I understand. When you were appointed as the bargaining representative of the employees, were you doing that in your own capacity or were you doing that on behalf of APESMA?‑‑‑I, along with three other pharmacists employed by National Pharmacies, was in this bargaining committee and we were bargaining with National Pharmacies with assistance by APESMA.

PN801

Right. So you were, in effect, with others appointed as the bargaining representatives on behalf of the entire National Pharmacies workforce. Would that be correct?‑‑‑That is correct.

PN802

And APESMA wasn't appointed as a bargaining representative. They merely assisted you in the negotiations?‑‑‑That is correct.

PN803

I also understand, Ms Malakozis, that you are a member of the Professional Pharmacist Australia Committee, that's so, for APESMA?‑‑‑That is correct.

***�� KATERINA MARIA MALAKOZIS�� XXN MR SECK

PN804

And in negotiating the enterprise agreement on behalf of employees and receiving assistance from APESMA, did APESMA provide you with input in terms of tactics and strategies in negotiating the enterprise agreement?‑‑‑I don't believe that they provided tactics. They merely assisted us in the negotiation process whilst we were negotiating with our employer.

PN805

All right. Did they - now, in your role as a committee member of the PPA are you aware of any other enterprise agreements which have been negotiated in the community pharmacy sector besides National Pharmacies?‑‑‑No. I am not sure of any other community sector pharmacies.

PN806

Okay. Now, in negotiating the agreement, what I assume you have done is you have looked at the award, but because there have been several generations of enterprise agreements which have been applicable to National Pharmacies, what you have sought to do is to build from the previous enterprise agreements. Would that be correct?‑‑‑That would be correct.

PN807

And the award itself, whilst it prescribes minimum conditions of employment, it wasn't something to which you had specific regard in negotiating the enterprise agreement?‑‑‑So we would use the industry award as the base.

PN808

Yes?‑‑‑And as you have already mentioned, we have just built on the enterprise agreement from negotiation to negotiation to better it for our pharmacists.

PN809

Okay. Now, can take you back to your statement, exhibit 6, Ms Malakozis? You say you've worked as pharmacist-in-charge since 1993 and that has progressed through various sizes of pharmacies within National Pharmacies. Is that so?‑‑‑Yes. That is correct.

PN810

And the staffing within those pharmacies would have expanded as you have progressed to larger pharmacies during your career,?‑‑‑Yes. Correct.

PN811

VICE PRESIDENT HATCHER: Can we just pause for a second.

PN812

Ms Knowles, it has just been brought to my attention if you look at paragraph 19 and 20 of Ms Malakozis' statement, there seems to be some drafting interpolations.

***�� KATERINA MARIA MALAKOZIS�� XXN MR SECK

PN813

MS KNOWLES: Yes. My apologies Vice President. That is not actually the correct copy that should be in the folder.

PN814

VICE PRESIDENT HATCHER: Well, I am not necessarily using your folder. I am using the version that was filed.

PN815

MS KNOWLES: Yes. It's actually in my folder. But that - - -

PN816

VICE PRESIDENT HATCHER: Anyway, so we just simply strike those from the statement?

PN817

MS KNOWLES: Yes.

PN818

VICE PRESIDENT HATCHER: I don't know if there are others, but there is one in the fourth line of paragraph 19. So we will strike out what is in the square brackets and in the third and fourth lines of paragraph 20, which we will strike out what is in the square brackets.

PN819

DEPUTY PRESIDENT DEAN: Ms Knowles, is it otherwise the same document as the document in your - - -

PN820

MS KNOWLES: I would have to double-check. I don't know how this version made it into the folders, but I did realise that there was an earlier version floating around - I'm not quite sure - which is not the version, as I understand it, that was filed.

PN821

DEPUTY PRESIDENT DEAN: So what version has the witness just sworn to being true and correct? Was it this - do we need to look at that other version?

PN822

MS KNOWLES: I think - well, in my discussion with Ms Malakozis before, I asked her to bring the version that wasn't this version, but I - so she should have the version as filed.

PN823

VICE PRESIDENT HATCHER: This is the version as filed.

PN824

MS KNOWLES: Is it?

PN825

MR SECK: It's the version I've got as well.

***�� KATERINA MARIA MALAKOZIS�� XXN MR SECK

PN826

DEPUTY PRESIDENT DEAN: Is there a different version in the folders that you handed up yesterday?

PN827

MS KNOWLES: Well, I thought that there was a version without these things in the paragraphs that had - that was the one that has been filed. But if that is incorrect - right.

PN828

Ms Malakozis, can I take you to paragraph 19 of the settlement that you've got in front of you?‑‑‑Yes.

PN829

And if you go to the fourth line is there something in brackets there?

PN830

DEPUTY PRESIDENT DEAN: Other than PSA?‑‑‑Yes.

PN831

MS KNOWLES: There is. Okay.

PN832

VICE PRESIDENT HATCHER: All right. So we've got - we're all on the same page. All right. Thank you. Mr Seck?

PN833

MR SECK: Your Honour, just for the record, I think paragraph 11.17 on page 3 has the same issue and so I'm content for the words - - -

PN834

VICE PRESIDENT HATCHER: Yes. So we will strike that out.

PN835

MR SECK: Yes. Strike that out as well, I assume. But I - so I think paragraph 11.17, paragraph 19 and 20 are the only ones I pick up.

PN836

VICE PRESIDENT HATCHER: All right. Let's move on.

PN837

MR SECK: Ms Malakozis, before that interlude, I was asking you questions about the fact that you have worked through various sizes of pharmacies during your employment with National Pharmacies in your capacity as a pharmacist-in-charge and the question I asked you was whether or not the staff who were working under your supervision had increased during each of those occasions. Is that correct?‑‑‑Yes, that's correct.

***�� KATERINA MARIA MALAKOZIS�� XXN MR SECK

PN838

And at the moment, you identify in your statement that you have dispensary technician is an assistance who now help you in the dispensation of medication. That's in paragraph 12, yes?‑‑‑Yes. I do have them and I have had them in the past as well.

PN839

And you also have more than one pharmacist who was rostered on particular shifts?‑‑‑That's correct. There's two of us working during the normal hours of 9 till 5.

PN840

And obviously the workload which is imposed upon you as a pharmacist-in-charge and your fellow pharmacists will depend in part upon the level of staffing and assistance which is provided on any particular roster. Would you agree?‑‑‑Can you just repeat that question for me, please?

PN841

And obviously the workload that you have in any - on any particular roster is going to depend upon the number of staff members who are rostered on that particular shift. Would you agree?‑‑‑I don't - I can't say that the workload that we have depends on the number of staff that we have rostered. The workload that I would reflect on would be certainly different to the influence of the staff that are present. So, yes, we do have staff rostered at certain times of the day, but that is not necessarily subject to the work though that I personally have.

PN842

And when you are saying the workload you personally have, you are talking about the fact that as pharmacist-in-charge of the pharmacy that workload is going to be largely the same whether or not you have three staff or five staff, for example. Is that right?‑‑‑So the workload that I have would be as a pharmacists as well as a pharmacist-in-charge.

PN843

Right?‑‑‑It would be the same, yes.

PN844

But if you're both performing the job as a pharmacist as well as the pharmacist-in-charge, having other people such as another pharmacist present on shift is going to assist you in managing your workload much better. Would you agree?‑‑‑I would agree, because our prescription numbers warrant the two pharmacists present.

PN845

And that is also going to be of assistance if you have dispensary technicians also rostered in performing part of those tasks?‑‑‑Yes, that's correct.

PN846

Now, in your statement at various locations, if I can take for you, for example, to paragraph 13, but it's language which you use elsewhere, you refer to in paragraph 13 today, "There is so much more work." Do you see that?‑‑‑Yes, I do.

***�� KATERINA MARIA MALAKOZIS�� XXN MR SECK

PN847

And when you say "today", you are talking about obviously the time at which you sign the statement?‑‑‑Today I am referring to the current times.

PN848

And if you go to paragraph 12, you talk about the period when you were first trained in 1989 and 1990 and subsequent years. Do you see that?‑‑‑Yes.

PN849

And so what I gather you are doing, Ms Malakozis, is undertaking comparison between what had existed at the time when you were first trained in subsequent years to the present moment and that's what you mean by - that's what you are doing in your statement. That's so?‑‑‑Yes, that's correct.

PN850

And when you say "subsequent years" that covers the time period from 1989/1990 to what period?‑‑‑I am comparing recent years, so the last few years with the increase in workload compared to when I first started.

PN851

So when you say "recent years", I must say when I read your paragraph 12, you talk about your work revolving around prescriptions, accurate dispensing et cetera and then you go into paragraph 13 and comparing it. So am I not right in saying that when you talk about today in your comparison with what was the case, you were doing it from 1989/1990 onwards?‑‑‑My reference for today would be the last perhaps three to five years.

PN852

I understand. And then what was your reference to - what was the comparison period you were using?‑‑‑My early pharmacist years, if I can compare from the 90s. So from about 1993 when I was pharmacist-in-charge at a small location up until about 99 when I moved to a larger store.

PN853

Okay. So in understanding your statement, you are comparing the 1993 to 1999 period to the last three to four years. Would that be correct?‑‑‑Yes. The last three to four years are the ones that we significantly see a change.

PN854

All right. Now, the comparison you make initially is in relation to the workload. In paragraph 13 you say, "Today there is so much more work on our daily tasks." So by that, I gather that you mean the range of work as well is the amount of work. Would you agree?‑‑‑Yes. So there's a wider scope of work that we perform and there is greater depth in what we do.

PN855

Right. And when you were initially trained as a pharmacists, Ms Malakozis, and this is when you - in 1989 and 1990, would it be fair to say that your job involved dispensing and providing advice as to the safe and judicious use of medicines?‑‑‑That is correct.

***�� KATERINA MARIA MALAKOZIS�� XXN MR SECK

PN856

And that would involve both dispensation of prescription medicines and supplying over-the-counter medicines. That's right?‑‑‑Yes.

PN857

And also providing advice to patients about the proper use of those medicines, dosages, after effects and any potential adverse interactions with other medicines. That's so?‑‑‑Yes. So it would be we would obviously assist the patients with their medication and understanding how to use them.

PN858

And as part of your job - I'm talking about when you first started and during your time in your initial years as a pharmacist-in-charge - in providing that advice about the proper use and dosage of medicines, you would have to obviously engage in communication with patients to ascertain what medications they were using. Would that be fair?‑‑‑Yes, we would.

PN859

Their particular personal and health circumstances?‑‑‑Yes.

PN860

The particular illness or ailment from which they were suffering?‑‑‑On the odd occasion, that is correct.

PN861

When you say "on the odd occasion", wouldn't you have to identify the particular ailment or illness to understand the appropriate medication which should be offered to them as part of addressing those issues?‑‑‑Those decisions are obviously from the general practitioner and certainly we have an understanding of the conditions and the medications that treat those conditions. In the - in my early years as a pharmacist and I have a vague recollection, but I don't think that we were as much involved in the patient care as to finding out particular illnesses as we do today. So I believe today there is a lot more interaction. There is a lots more discussion with the patient about their conditions. Patients are a lot more open and willing to discuss and there is a lot more interaction today than there was back then.

PN862

You say "a lot more" and "you don't do it as much", which suggests to me that you did do it during your early years as a pharmacist, it's just that the amount of interaction and communication between a pharmacist and a patient has increased. Would that be fair?‑‑‑Yes. So the amount of interaction we have today involves a lots more knowledge - well, knowledge - I shouldn't say knowledge. There is a lot more interacting. So with your patient you are aware of who they are. You are aware of their conditions You are aware of all their treatments and you are able to assist them. When I first started as a pharmacist, I don't recall that we had such connection with our patients to know what they were being treated for. It was really almost like a supply and assistance with their medication.

***�� KATERINA MARIA MALAKOZIS�� XXN MR SECK

PN863

I am just interested in the answer you gave beforehand, Ms Malakozis, so I just want to explore it with you. You said you didn't do it as much. Now, by saying that you didn't do it is much and that you are doing it more now, that implicitly suggests that you didn't do it last time, but it has expanded over time. Would you say that's a fair assessment of what occurred?‑‑‑Yes.

PN864

And so really what is happening now involves the same deployment of skills that you had when you started as a pharmacist in charge. It's just that the level of interaction now is much greater than what previously existed. Would that be fair?‑‑‑I think the skills have changed. There is more engagement with our patients now. There is more responsibility with what we do, so I think it's greater now than it was.

PN865

You say "more" and "greater" in terms of responsibility and interaction. So let me explore that with you. In terms of interaction, that means more time is being spent with patients in exploring their health conditions and explaining to them the best medication and other health treatments which might be available in addressing them. Would that be fair?‑‑‑That's right. So more time spent with the customer. More research, if you like, to make sure that we are giving the right information; more engagement with the customer and ongoing communication with them. So it may not be just that moment. It will be following through as well.

PN866

And so when you talk about more skill and that was, I think, the other part of your answer, what you are talking about is more skill in being able to engage with the patient in trying to develop that therapeutic connection with them in addressing the medical needs?‑‑‑I think I said the skills are different in that it's more of a - it's a whole solution now with the whole health care of the patient. So it's not only the prescription medication that they bring in, it's the other care that we can assist with for their particular condition. So it's not only the medication. It's the whole health care.

PN867

So you talk about the other care you can provide them. The other care would be using your skills as a pharmacist to go beyond dispensation of the medicines, but also advising them as to what kind of issues?‑‑‑Well, there may be some other information we can assist them with, whether it's other allied healthcare professionals or whether it's other over-the-counter healthcare products that we can assist with their condition. It's offering them a greater solution where possible.

***�� KATERINA MARIA MALAKOZIS�� XXN MR SECK

PN868

So it's, as I understand it, the additional skills we're talking about; other medications which might be available to them and other healthcare providers - allied healthcare providers who might be able to assist. Is that correct?‑‑‑That's correct.

PN869

That would have been something which was within your skill set to undertake from the very start. It is just that now the business model for dealing with patients has changed. Would you agree?‑‑‑Yes. I would agree.

PN870

So in reality there has been no change in terms of the deployment of skill or the skills that you have, it's just that the deployment of those skills is much greater in a different business environment?‑‑‑Yes, so greater - yes, the skills are greater. As mentioned, there's more engagement, greater responsibility.

PN871

But in saying "greater", I think what you are saying is that you have - the skills are different, it is that you are deploying them over - during a longer period, because you are engaging with the patients for longer. Is that so?‑‑‑Yes. And we seem to have influence in customer healthcare as well.

PN872

So what I want to put to you is that the skills aren't different, but it is the time in which you are deploying those skills which is different?‑‑‑Not necessarily, the time - well, the time, but it's probably the way we use those skills.

PN873

And when you say - - -?‑‑‑It's not only a time factor.

PN874

Okay. So it's partly the time factor, but it's the way in which the skills are deployed. And am I right in saying that when you say "the way in which the skills are deployed", you are talking about the level of engagement in obtaining information from the patient and the level of information you provide the patient?‑‑‑Yes, that's right.

PN875

But those of the same skills. They are just being deployed over a - at a more deeper level. Would you agree?‑‑‑They are the same skills, but we need to make it known that today we have so many other areas that we assist the customer. So it may not necessarily mean, for example, that we are assisting them with their particular condition, but inoculation, flu vaccination, MedsChecks - all of that are an additional point now that we are saying that our skills are different. We are still providing the service that we did in my early registration years, but our skills are different from that perspective as well.

***�� KATERINA MARIA MALAKOZIS�� XXN MR SECK

PN876

Let's use that as an example of MedsCheck, and the skills which you say are different. MedsCheck, am I right in saying, is a review of the medication by the pharmacist of a patient to ascertain whether or not the medication which is being taken by the patient is effective in dealing with their particular health needs. Would that be a fair assessment of what MedsChecks involve?‑‑‑MedsChecks involves the entire medication that the customer is taking as well as over the counter products, so that interaction involves making sure the customer understands what they are taking, how they work for them, if there are any issues that arise if the customer doesn't understand how to take them and then, you know, compatibility with over-the-counter medications, and then they are provided with a report.

PN877

And you have always had the skills to be able to do those things, would you agree, Ms Malakozis?‑‑‑The skills to do, but the means to do we haven't had. So the means to provide a MedsCheck was not there. Now it is. There is a performer and it is a lot easier to do.

PN878

So the means you are talking about is a form and now some government subsidies under the Community Pharmacy agreements?‑‑‑Yes, correct.

PN879

Would that be also similar in relation - excuse me. Now, in relation to - let's use another example, Ms Malakozis, which is dose administration aids. You say that paragraph 16, they're in greater demand by elderly persons. Do you see that?‑‑‑Yes.

PN880

When you say they are in demand, that suggest to me that that's a greater demand now compared to what it was previously. Would that be fair?‑‑‑Yes, that's correct.

PN881

But DAAs would have been something National Pharmacies and you would have been doing in the 1990s?‑‑‑I have been doing them - I don't remember doing them in the 1990s. I have been doing them since about 2005,2006.

PN882

Were you aware of DAAs being provided or offered by pharmacies prior to 2005, 2006?‑‑‑What I knew was that there were organisations that provided them as a group. So, for example, nursing homes. But in pharmacy we - I don't recall that we actually performed them at National Pharmacies.

PN883

All right. Your experience is obviously only based on what National Pharmacies was doing and not what other pharmacies may have been doing prior to 2005?‑‑‑That's right.

PN884

Yes. Okay?‑‑‑Yes. That's correct.

***�� KATERINA MARIA MALAKOZIS�� XXN MR SECK

PN885

Now, in paragraph 18, Ms Malakozis, you say you may need to apply first aid and I think you recommend - there's a missing word there, "to a customer" or "deal with a customer by calming them down and relaxing them." Those would have been situations that would have been posed to you during the entirety of your career as a pharmacist. Would you agree?‑‑‑So as a pharmacist, correct. We were required to have a first aid certificate, but what I intend to say in paragraph 18 is that we find that many people come into our pharmacy first-aid as the first point of call. So they may well have an injury that may require, for example, stitches or to see a GP, but the first port of call we find seems to be the pharmacy now.

PN886

When you say "now", it would have been situations that would have arisen during your time as a pharmacist since the early 1990s that people would come in and say, "Look, I need to have someone help me put on wound dressing." That would have been a scenario or situation that may have occurred or would have occurred from the very start of your career?‑‑‑That's right, yes. That may have occurred, but as I mentioned, I feel that we - - -

PN887

VICE PRESIDENT HATCHER: I didn't hear the last part of that answer. Can you repeat that again?‑‑‑Yes. That is something that the patients have done for us, or have requested of us, but I feel like in the current years that was have customers coming in as the first port of call for any type of first aid and they should be going to a hospital or a doctor and yet they come into the pharmacy now.

PN888

MR SECK: And that's really because pharmacies are trying to educate patients as to where they need to go as a first port of call in dealing with first aid issues. Would you agree?‑‑‑Yes. That could be the case. Yes.

PN889

And you say in paragraph - - -

PN890

VICE PRESIDENT HATCHER: Sorry, just before you go on, to the extent you say that you have observed to a greater degree people coming to pharmacists as a first port of call, is that something you have simply observed as a social phenomenon or do you link that to some change in the role of the skill set of a pharmacist?‑‑‑Well, pharmacy has been one of the most - pharmacists have been one of the most trusted professions for many years. So I believe that the customer trust the pharmacists to assist and to help them make decisions perhaps. So therefore from a health perspective, I feel like it's just a natural thing for them to do to see the pharmacist as the first point of contact for a health situation.

PN891

MR SECK: And that is a phenomenon; that is, the level of trust which you observe between a pharmacist and a patient that has existed throughout your career as a pharmacist. Would you agree?‑‑‑Can you repeat that, please?

***�� KATERINA MARIA MALAKOZIS�� XXN MR SECK

PN892

The phenomenon in which is just been described by the Vice President; that is, the tendency for - - -

PN893

MS KNOWLES: I object to that. He didn't describe it as a phenomenon, he asked whether it was a phenomenon or a change in the skill set.

PN894

VICE PRESIDENT HATCHER: Yes. I think that's right, Mr Seck.

PN895

MR SECK: Sorry. I may have been sloppy in my language, but let me put it a different way. Let's not - let's de-link it from the Vice President's question. The observations that you referred to beforehand, Ms Malakozis, that you think patients come into a pharmacist to deal with first-aid issues because there is a level of trust that exists between a pharmacist and a patient has been an observation you have made from the very start of your time working as a pharmacist. Would you agree?‑‑‑So that's an observation that I have made. Well, that's correct. So from the start of my career, we have had the trust, but I think in recent years there has been an increased trust towards the pharmacist because of the greater interaction that we have been having with our patient.

PN896

Now, you say in paragraph 18 in the second sentence that where there is the particular issue in relation to dosage of prescription, you may need to clarify with the doctor or ring them up to read their handwriting. That is something you have been doing since you began as a pharmacist, would you agree?‑‑‑Yes. I do agree.

PN897

In paragraph 19 you refer to your management responsibilities to ensure that team members are compliant with professional practice standards and code of ethics. Do you see that?‑‑‑I do.

PN898

Now, you said earlier that you have been a pharmacist-in-charge since 1993. It's the case, is it not, that there have been competency standards, professional standards and codes of ethics in place for pharmacists since that time; since you began as a pharmacist-in-charge?‑‑‑I believe there is or there was.

PN899

And so the management responsibilities that you refer to in paragraph 19 are responsibilities that are being consistent since your time working as a pharmacist-in-charge. Would you agree?‑‑‑I agree, but over the years I think there has been an expansion of these documents. So there is a - there is more in these documents than there were when we first began; when I first started as a pharmacist.

***�� KATERINA MARIA MALAKOZIS�� XXN MR SECK

PN900

So when you say an expansion, there have obviously been changes in pharmaceutical products and medicine, which would mean that there is a concomitant expansion in standards in dealing with each of those issues, would you agree?‑‑‑Yes.

PN901

But there has been an expansion in those issues consistently since 1993, would you also agree? That's just the very nature of medicine, that there are more medicines which come on to the market and therefore standards are developed to deal with those new medicines?‑‑‑That's correct. But also there are standards to develop in the code of ethics or the - not only supply, but professional behaviours and those type of standards as well.

PN902

When you say "professional behaviours and standards", there have always been standards regulating professional behaviours, promulgated by the Pharmacy Board or the relevant state or territorial authorities, would you agree?

PN903

MS KNOWLES: If the witness is going to be asked questions about these documents, I ask that they be put to her. Because it is not clear what documents are being referred to.

PN904

MR SECK: Well, I am referring to the documents that she is referring to in paragraph 19. She talks about professional practice standards. I should be entitled to ask questions, if she is referring to professional practice standards, just to ask are that to the best of her knowledge - - -

PN905

VICE PRESIDENT HATCHER: Yes. I will allow the question.

PN906

MR SECK: May it please.

PN907

Now, to the best of your knowledge, Ms Malakozis, there have always been professional practice standards which have been applicable to pharmacists promulgated by the Pharmacy Board of Australia or other state and territory - or the South Australian Pharmacy Regulatory Authority, would you agree?‑‑‑Yes.

PN908

And so in your role as the pharmacist-in-charge, it has been consistent that you had the obligation to ensure that there has been compliance with those practice standards imposed since 1993?‑‑‑Yes, that's right.

PN909

Now, in paragraph - pardon me, I'll find the paragraph. IN paragraph 21 of your statement, Ms Malakozis, you say in the second sentence:

***�� KATERINA MARIA MALAKOZIS�� XXN MR SECK

PN910

Today we have a broad hierarchy of guidance and regulation of pharmacy practice.

PN911

You say,

PN912

This begins with legislation, both Commonwealth and State.

PN913

Now, would you agree that in 1993 there was legislation, both Commonwealth and State, regulating pharmacy practice?

PN914

MS KNOWLES: I make an objection. What Ms Malakozis has referred to in paragraph 19 and 21 are the current professional practice standards in the new code of ethics, and in paragraph 21 she talks about legislation today. If she is going to be asked about legislation in the early 19902 or, for that matter, professional practice standards and codes of ethics at that time, we need - something needs to be put to her about what that is and what the question relates to.

PN915

VICE PRESIDENT HATCHER: Well, the second sentence begins with the words, "Today we have a broader hierarchy", et cetera, and then that is explained. I think Mr Seck is entitled to explore whether today is any different from the position that prevailed at some earlier point in time. Obviously, we are dealing with, at this stage, a high level of generality and not dealing with specific legislation, which if Mr Seck wants to raise, he can, but might need to show the document to the witness. So I will allow the question.

PN916

MR SECK: May it please.

PN917

Ms Malakozis, I will ask the question again. You will see in paragraph 21 of your statement, you talk about a broad hierarchy of guidance and regulation of pharmacy practice. You refer to legislation both Commonwealth and state, which exists today. Do you see that?‑‑‑I do. Yes.

PN918

What you are seeking to do is demonstrate that this has changed over the years, as you say in your first sentence at paragraph 21. That's so?‑‑‑Yes, with increasing professional demands.

***�� KATERINA MARIA MALAKOZIS�� XXN MR SECK

PN919

Yes. So when you are saying "increasing professional demands" you obviously are undertaking a comparison between what you say exists now and what had existed in the past. Do you agree?‑‑‑What I am saying is that with all these guidelines, the demands on the pharmacist are enhanced to comply with all of these that seem to have expanded in recent - well, I won't say in recent years, but seem to have expanded.

PN920

Okay. So when you say its expanded, you are obviously making comparison with a situation which existed in the past. Do you agree?‑‑‑I feel that when I first started in pharmacy that there wasn't the depth of what we have today with our guidelines.

PN921

Well, so to get to the crux of the issue, it's not the fact that guidelines standards and legislation and codes did not exist when you started. You are just simply saying now that there are more of them. Would that be fair?‑‑‑I can't comment if there are more of them but I believe that the depth is there. There is greater depth in those documents.

PN922

And when you say "depth", you mean there is more content in those documents?‑‑‑Yes. That's right.

PN923

And more content is to provide you with specific guidance as to what you should or shouldn't do in particular situations. Correct?‑‑‑Yes, correct.

PN924

We discussed previously, part of that is due to the fact there's been, by the nature of science, more medications which are being released. Would you agree?‑‑‑Possibly.

PN925

And pharmaceutical practice has evolved over time and that is another reason for why there are further guidelines and standards on particular topics?‑‑‑Yes.

PN926

And would you agree that that has really been something that has occurred from 1993 to the present day?‑‑‑I don't believe I can categorically state that it has been since 1993.

PN927

And that is because you don't know or you are not sure?‑‑‑I am not sure.

PN928

Right. So you can't deny the proposition that there has been a gradual expansion of standards and codes since the time you have been working as a pharmacist?‑‑‑Since the time I've been working as a pharmacist, I have - believe that there is an increased number of codes and depth of detail.

PN929

Right. From 1993 to now? Just so I'm clear, from 1993 to now. Is that so?‑‑‑Yes.

***�� KATERINA MARIA MALAKOZIS�� XXN MR SECK

PN930

Okay. If your Honours will just bear with me. No further questions.

PN931

VICE PRESIDENT HATCHER: Any re-examination, Ms Knowles?

RE-EXAMINATION BY MS KNOWLES�� [10.55 AM]

PN932

MS KNOWLES: Briefly, Vice President.

PN933

So Ms Malakozis, you were asked by Mr Seck if you were giving a comparison between 1993 and 1999, that period, versus the last years and then your response to that was you said, "In the last three to four years, that's when there's been the most changes." What were those changes that you were referring to?‑‑‑So those changes would relate to the workload that we have. So we have always had the means to do blood pressure testing, for example. However, today there is a lot more engagement with the customer. They want blood pressure testing. They want blood sugar testing. They want cholesterol testing. We have as mentioned already an increased number of dose administration aid request. We have family members requesting them. We have GPs requesting them. We have customers themselves requesting them. People are on a lot more complex medication regimes.

PN934

And what do you mean by that, Ms Malakozis? When you say people are on a much more complex medication regimes?‑‑‑So there are a lot more medication available, for example, for blood pressure and they're on - they may well be on two or three different blood pressure medications that act at different points in the body, obviously. And then they may well be on cholesterol medication, diabetes medication, arthritis medication. So that what's I refer to as a complex regime; treating various conditions and they may be the reasons why we have an increased request for dose administration aids.

PN935

COMMISSIONER SPENCER: Can I just understand with that; is that the pharmacist putting a plan together of when the time that those medications should be taken and then putting - does the pharmacist put that pack together or do you have someone within the pharmacy putting that DAA together?‑‑‑We mainly have pharmacists that do that in our location.

PN936

So that is distributing that into some sort of - you tell me what that involves?‑‑‑So it's like blister pack with pockets that are four times across. So for example, morning, lunch, dinner, bed time and then seven pockets down, so it's four by seven. So you have seven days' worth of - a week's worth of medication. So it's basically filling in - - -

***�� KATERINA MARIA MALAKOZIS�� RXN MS KNOWLES

PN937

You would work out when they would take that and you would actually prepare that, the pharmacist-in-charge?‑‑‑Yes. That's correct. The pharmacist, not necessarily the pharmacist-in-charge, but the pharmacist.

PN938

Right. That could be delegated to someone else within the pharmacy to prepare?‑‑‑That could be delegated to someone else. The pharmacist has to do the final check and it is a process where we can have someone else do it if there are - if the medication is not very complex or there's not a lot of tablets, but when there are - it's quite a complex regime, it is best for the pharmacist to do them.

PN939

Thank you?‑‑‑And just to continue on with the workload, we are involved, obviously, in supplying diabetes consumables - testing strips - on behalf of the national diabetes service scheme. We offer weight loss programs for customer. That has regular appointments. Vaccinations is the other thing that I do, so I do flu vaccinations and people just walking off the street at any time and we are required to do flu vaccinations. Sick certificates is another thing that we do now. So once again, people coming in off the street and requesting to speak to the pharmacist about sick leave certificates. Medication checks, we've already mentioned, or med checks we've already mentioned. And now, of course, we have compulsory continuous professional education that we need to attain to maintain our registration. So we've always to do that for our own benefit, but it's now compulsory to do so that we can register every year. So they're just a few examples.

PN940

You were asked some questions in relation to professional standards and guidelines and you said that there had been an expansion in the document - there had been more in these documents than when you first began. In what way has there been more in those documents?‑‑‑Well, I can't give you specific examples, but my recollection is that when these documents are released they seem to be - there's more topics in these; there's more categories that are inserted. So I just feel like they get thicker and thicker basically.

PN941

No further questions.

PN942

VICE PRESIDENT HATCHER: Thank you for your evidence, Ms Malakozis. You're excused and free to go?‑‑‑Thank you.

<THE WITNESS WITHDREW�� [11.02 AM]

PN943

VICE PRESIDENT HATCHER: Ms Knowles, the next witness is Mr Le, is that right?

***�� KATERINA MARIA MALAKOZIS�� RXN MS KNOWLES

PN944

MS KNOWLES: Yes.

PN945

VICE PRESIDENT HATCHER: All right. So we'll have to get her by telephone.

PN946

MS KNOWLES: Yes, Vice President.

PN947

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

PN948

MR LE: Cardin Hine(?) Le, (address supplied).

<CARDIN LE, AFFIRMED�� [11.03 AM]

EXAMINATION-IN-CHIEF BY MS KNOWLES�� [11.03 AM]

PN949

VICE PRESIDENT HATCHER: Ms Knowles?

PN950

MS KNOWLES: Mr Le, have you prepared a statement for these proceedings?‑‑‑Yes, I have.

PN951

Is that a statement dated 15 December 2017 which is five pages long and 20 paragraphs long?

PN952

VICE PRESIDENT HATCHER: No, it's the 13th, not the 15th.

PN953

MS KNOWLES: Sorry, this folder I have has all these different copies of things in them and because the names have been blacked out it's hard to see, so thank you, Vice President. My apologies, Mr Le. It's a statement dated 13 December 2017 which is three pages long?‑‑‑Yes.

PN954

And 18 paragraphs long?‑‑‑That's correct.

PN955

Are the contents of that statement true and correct?‑‑‑That's correct.

PN956

I tender that.

PN957

VICE PRESIDENT HATCHER: The statement of Cardin Le dated 13 December 2017 will be marked exhibit 7.

***�� CARDIN LE�� XN MS KNOWLES

EXHIBIT #7 WITNESS STATEMENT OF CARDIN LE DATED 13/12/2017

PN958

MS KNOWLES: No further questions.

PN959

VICE PRESIDENT HATCHER: All right. Mr Seck, who is representing the Pharmacy Guild will ask you some questions now, so please tell us if you have difficulty hearing anything he says?‑‑‑Okay.

PN960

Mr Seck?

PN961

MR SECK: Thank you, your Honour.

CROSS-EXAMINATION BY MR SECK�� [11.05 AM]

PN962

MR SECK: Mr Le, do you have a copy of your statement in front of you?‑‑‑Yes, I do.

PN963

You say you completed your Bachelor of Pharmacy degree from Charles Sturt University in 2009, that's so?‑‑‑That's correct, yes.

PN964

Did you work in a pharmacy prior to 2009 in any other capacity?‑‑‑Yes, in 2008 I was working in like a beauty pharmacy as a pharmacy assistant.

PN965

What was the name of the pharmacy?‑‑‑It's called Kooringal Pharmacy.

PN966

Did you ever undertake a role as a pharmacy intern?‑‑‑Yes, that was in 2010.

PN967

Where was that?‑‑‑I done the first half of the year at the Wagga Base Hospital in Wagga Wagga, and the second half in a community pharmacy.

PN968

Mr Le, you say you now work as pharmacist in charge at Cincotta Chemist in Wagga Wagga, that's so?‑‑‑Correct.

PN969

And just your current pay for ordinary hours of work is $37 per hour, yes?‑‑‑Correct.

***�� CARDIN LE�� XXN MR SECK

PN970

It says in paragraph 10 you entered into an individual flexibility agreement with your employer, do you see that?‑‑‑Yes.

PN971

Can you explain to the Commission the circumstances in which you negotiated the individual flexibility agreement with Cincotta Chemist?‑‑‑Sure. When I spoke with the owners of the pharmacy, he stated to me what he needs me to do at the pharmacy. Obviously looking after the dispensary, looking after staff, the stock orders, compounding products that is not available for order, and reports to the owner a year. And with that, normally he pays $35 to the pharmacist, but he was happy to pay me $37 per hour, $45 per hour on Saturdays, and $50 on Sundays and public holidays. I was happy with that and we agreed to that.

PN972

So you signed an individual flexibility agreement, is that right?‑‑‑Yes. I signed the agreement to state that I'm happy to do that, and that sits with the current employer.

PN973

When you did that, was that part of a negotiation which took place with Cincotta Chemist?‑‑‑No, just a verbal discussion with the owners and they are happy to do that.

PN974

And you were happy - - -?‑‑‑Yes, we're both happy to do that.

PN975

At the time you entered into the individual flexibility agreement, were you aware of the rate of pay that applied to pharmacists in charge under the Pharmacy Industry Award?‑‑‑Yes, I'm aware it's lower than what was agreed, but I mean, it's normal now in the pharmacy industry that the pharmacist in charge is paid slightly higher, and even when I was just a pharmacist on duty I still get paid higher than the award.

PN976

Would that be the case in all the roles that you worked at as pharmacist in charge? I think you've got here, worked as pharmacy manager at Len Wade Pharmacy - is that a pharmacist in charge position, Mr Le?‑‑‑Yes. Initially I worked as a pharmacist in charge, but a few months later I got promoted to pharmacy manager to cover the whole shop - yes, and the rate of pay is much higher than $37 per hour where I am now.

PN977

So how much did you get paid as pharmacist manager at Len Wade Pharmacy?‑‑‑$42 per hour.

PN978

Did you negotiate an individual flexibility agreement at Len Wade Pharmacy?‑‑‑In the same fashion, yes.

***�� CARDIN LE�� XXN MR SECK

PN979

What flexibilities were negotiated as part of your individual flexibility agreement?‑‑‑Yes, not only they pay $42 per hour; they also give me a travel allowance as well, because I'm coming from Wagga to Len Wade, which takes about an hour/an hour and 15 minutes driving each way.

PN980

And the travel allowance was part of the negotiation that took place with the owner of Len Wade Pharmacy?‑‑‑That's correct, yes.

PN981

Were there any other benefits you received under the individual flexibility agreement with Len Wade Pharmacy, Mr Le?‑‑‑That is all. That is all that's part of the agreement in terms of wages and pay.

PN982

You said you were initially employed as pharmacist in charge, and then you got promoted to pharmacy manager, which meant you were in charge of the entire shop?‑‑‑Yes.

PN983

What was the rate of pay you were earning as pharmacist in charge at Len Wade Pharmacy?‑‑‑It was, from memory, $40, I think.

PN984

Did you similarly negotiate an individual flexibility agreement in your role as pharmacist in charge?‑‑‑At the time?

PN985

Yes?‑‑‑At the time, yes. It wasn't much of an agreement. It was what was put on the table and I accept.

PN986

You accepted it because you were happy with the agreement presented to you?‑‑‑Yes, that's correct.

PN987

You also worked as the pharmacist in charge at Terry White Chemist in 2011 to 2014, that's so?‑‑‑That's correct.

PN988

Where was the Terry White Chemist?‑‑‑That's in Albury, new suburbs.

PN989

Do you recall how much you got paid as pharmacist in charge at Terry White Chemist?‑‑‑I was offered $35 an hour.

PN990

You were offered, and that was the rate at which you were engaged?‑‑‑That's right, and I accepted at the time.

***�� CARDIN LE�� XXN MR SECK

PN991

Would it be fair to say that was your first job as a pharmacist in charge?‑‑‑That's correct.

PN992

Again, did you enter into an individual flexibility agreement at Terry White Chemist in Albury?‑‑‑Yes, I did.

PN993

And again, what benefits did you receive under the individual flexibility agreement?‑‑‑Apart from $35 an hour during week days, I think I got a bit higher on the Saturday and a bit higher again on a Sunday. My role is similar in the community pharmacy, but at the time I also had to do a private hospital as well, and also delivery of some cancer drugs to the private hospital.

PN994

When you say you also had to do private hospital and cancer drugs to the private hospital, was that part of your role with Terry White Chemist or was that a separate - - -?‑‑‑Part, that's correct; that was part of my role at the Terry White Chemist, yes.

PN995

I think you're also a member of the Professional Pharmacists Australia committee at the moment, is that right, Mr Le?‑‑‑That is correct, yes.

PN996

In being presented with an individual flexibility agreement, and you understand an individual flexibility agreement is an individual agreement which can be made under the Pharmacy Industry Award, that's so?‑‑‑That's correct, yes.

PN997

And allows you to negotiate terms and conditions to allow for flexible work practices so long as certain conditions are met under the award, that's your understanding?‑‑‑Yes.

PN998

If you go to paragraph 14 of your statement, you say, "Since 2010, I observed demand for services has increased." Do you see that?‑‑‑Yes, I do see that.

PN999

And then you say, "I am now providing more counselling to patients", et cetera?‑‑‑Yes.

PN1000

So I gather from what you're saying there is that those services, there's firstly a greater demand from patients, yes?‑‑‑Yes.

PN1001

And that means patients are walking through the door and asking for the particular services you've identified in paragraph 14?‑‑‑Right.

***�� CARDIN LE�� XXN MR SECK

PN1002

Yes, is that right?‑‑‑Yes - well, what I am saying there is that what we normally do in 2010 is pharmacists, as I've observed, which is dispensing and counselling patients on an informal basis, so we dispense the medication, drug selection, et cetera; we put the label on a box, we check with the patient to make sure that they know what the drug is or whether they've taken before or how to take it, et cetera. At the same time we do a bit of informal review of their medication history through talking to them and just to make sure that it's safe for them to use. Since then, it becomes formalised now.

PN1003

So we not only need to informally talk to them, we actually need to make a time to review their medication. So we ask them to make a time, come in, sit down, bring all their medication in from home - inhalers, eye drops, et cetera - and then we sit down. We get them to sign an agreement that they're happy for their privacy or for their discussion of what the medications are, and then we document and write a report. If there's anything that they don't need at the time or no longer need it, we discuss with the doctor to cease it. If we find that there's an interaction with the new medication to their existing medication (indistinct), then we discuss with the doctor again and see whether we should cease or introduce another medication.

PN1004

All this now has to be formalised into a document, into a report, and then send that to the doctor, a copy given to the patient, and then out of that the doctor will come back and say yes, I agree with you that this lady no longer needs this inhaler, or these drugs that I'm giving interact with her existing medication, and then from there the doctor will decide what to do next, and then we discuss with the patient again.

PN1005

MR SECK: You used the word that it used to be informal and now it has become formal, which suggests to me, Mr Le, and tell me if you agree, that the skills which you're deploying in doing that job is the same, but there's now appointments which are required and formal documentation of the particular things which need to be done. Would that be a fair description?‑‑‑In a way, yes, in terms of discussion with the patient. In terms of formalisation with the new practice for pharmacy, there's CPD required, or continued professional development required, which has increased from 30 to 40 points, and with that we need to gain further education into what's developed out in the pharmacy world or in the pharmacy industry; for example, the up‑scheduling and down‑scheduling of medication, what's new on the market, and that costs money. So for example, if I have to attend a conference in Sydney, it will cost me $995 just for the registration fee; there's travel, accommodation on top of that for the couple of days, and that's out of pocket. And then once we gain that education, obviously we're up‑to‑date with the knowledge of the pharmacy industry and then that's what makes us effective in formalising the documentation for the patients.

***�� CARDIN LE�� XXN MR SECK

PN1006

Mr Le, I note - you've got a few things which you've said there, but I am asking you a very specific question. So if you can listen to my question carefully and try to answer it, because I'll come to CPD and I'll come to all the things that you've just stated just beforehand. But I just want you to try to listen to my question and answer it, if you can, or the best you can?‑‑‑Yes.

PN1007

I talked about moving from an informal process to a formal process, and that was in response to an answer you gave to one of my earlier questions, and what I asked you was the change from an informal process to a formal process - and I think you agreed with this - was deployment of the same skills. What I was asking you was the changes which have occurred is now that there's a formal appointment required to sit down with the patient and then there's further documentation of those steps which are required. Those are the major changes, would you agree?‑‑‑Yes.

PN1008

In your capacity as a pharmacist from 2010, you said that your job initially was involved in the dispensation of medicine and counselling of patients as to - and I'm paraphrasing here - the use of those medicines. That's what you said, do you agree?‑‑‑Sorry, I missed that.

PN1009

In answer to one of the earlier questions I put to you, you said that your role when you started as a pharmacist in 2010 involved the dispensation of medicine and counselling patients as to the proper use of that medicine?‑‑‑Correct.

PN1010

Those still remain skills that you use on a daily basis in your capacity as a pharmacist, do you agree?‑‑‑Yes, to a small extent.

PN1011

So you're saying dispensing and counselling as to medicine is only a small part of your job, or is it still the major part of your job?‑‑‑It's only a small part of my job.

PN1012

Let me explore that with you. So you say in paragraph 15, "My normal working day involves dispensing 250 or more scripts." To me, that's still seems to me a significant part of your job. Is it a significant part of your job, or a small part of your job?‑‑‑Well, within a day, our pharmacy dispense about 350 scripts. In my eight‑hour shift, yes, I do about 250 scripts, with the assistance of a dispense team.

PN1013

Yes, of course. So would you agree that's a significant part of your job or a small part of your job?‑‑‑Within that eight hours it is a small part of my job.

***�� CARDIN LE�� XXN MR SECK

PN1014

So 250 scripts is actually not a huge amount in terms of the time it occupies on a daily basis?‑‑‑Correct.

PN1015

You say counselling patients as to the proper use of medicines is only a small part of your job. If you're dispensing 250 or more scripts, I'm assuming as part of dispensation of the scripts you're also counselling each of those patients as to the proper use of those medicines, do you agree?‑‑‑Yes.

PN1016

So in these pharmacies, you're the pharmacist in charge so I gather you're not the only pharmacist working at Cincotta Pharmacy in Wagga Wagga, would you agree?‑‑‑Yes. I do have another pharmacist, but our time overlap is only a couple of hours.

PN1017

So there are times when you're the only pharmacist present in the chemist, do you agree with that?‑‑‑Yes, I agree with that.

PN1018

As the only pharmacist in the chemist and according to paragraph 15, your normal working day involving 250 or more scripts, you would agree that you don't just dispense the scripts but you also provide counselling and advice to those patients as to the proper use of that medicine and any side effects and adverse interactions which may occur and using other medicines, do you agree?‑‑‑Yes, I agree. However, with 250 scripts, it doesn't mean 250 new scripts with new medication to 250 new patients.

PN1019

I understand. So just to pick up on that point, Mr Le, so there would be times where you're refilling a script, as it were?‑‑‑Yes.

PN1020

And you have already explained previously or had given advice to that particular patient previously as to the proper use of that medication, and there would be a component where there would be new scripts where you would need to give advice and counselling?‑‑‑That's correct.

PN1021

Do you agree?‑‑‑Yes.

PN1022

So do you still say that it's only a small part of your job, or would you say that counselling is a significant part of your job?‑‑‑Well, it would depend on the day. Dispensing is the smallest part of my job. Counselling, say, with a patient that had come back with a repeat, obviously I don't need to counsel them on that particular medication; however, with a medication review I would need to make an appointment with that patient and schedule a time to do a medication review, which I mentioned to you earlier, involving bringing in their medication, inhalers, eye drops, et cetera, and then sit down with them and do a formalised review and then submit the claim.

***�� CARDIN LE�� XXN MR SECK

PN1023

But that has always been a part of your skillset to actually do that, would you agree, Mr Le - that is, to review the medication and work out whether or not the medication which is being taken by the particular patient is appropriate?‑‑‑Yes. Well, in my opinion, standing and counselling informally with a patient would only take a couple of minutes, yes, so you would quickly review their history. But it's a different or slightly different skillset to actually sit down, review completely their medication history from whatever they take before, brought in from home, and then actually document that, create a report and submit the claim. That is a slightly different skillset to just standing there talking to the patient.

PN1024

So the skillset, just so I can explore that with you, Mr Le, is I think you said it's more formalised now; that's one aspect of it, that is, completion of documentation - that's one aspect of the skillset, yes?‑‑‑Yes.

PN1025

Another aspect of the skillset is that you're now reviewing all their medication as opposed to perhaps the medication which is being prescribed, that's right?‑‑‑Yes, that's right.

PN1026

And then, in conducting that review, you're exercising your skill and judgment to work out whether or not the suite of medications they're taking and the regularity of that medication is appropriate, correct?‑‑‑That's correct.

PN1027

I want to put to you what you're doing there is really a deployment of the skills that you've always deployed as a pharmacist, that is, working out whether or not the medication which is being prescribed for any patient is safe and judicious in the particular circumstances. Do you agree with that?‑‑‑I agree with that, but what I disagree with you, you're saying that the five minutes spent counselling the patient is the same as sitting down with a patient and reviewing all the medication. The five minutes standing there with the patient is just basically what we have on the system and what they answer to us. When they bring it in, they could have got it from another five different pharmacies. They could have taken some medication themselves, over the counter medication, like complementary medicine.

PN1028

I understand?‑‑‑So it's more involved, but obviously more time involved and more judgment involved, yes.

PN1029

So let's just tease that out. So the differences are it's longer, correct?‑‑‑Yes.

PN1030

And secondly, you're not dealing with the medications you've prescribed but other medications which may have been prescribed by other pharmacists and allied health service providers?‑‑‑Yes.

***�� CARDIN LE�� XXN MR SECK

PN1031

But you agree that's within your existing skillset to do all of that since you've started as a pharmacist?‑‑‑Yes, in a way.

PN1032

You say in paragraph 16 - let me go back; let me just stay at paragraph 14 for a moment. You use a whole lot of other examples, and I don't want to - in fact, let me skip over that. Pardon me, Mr Le; I will move on to another topic?‑‑‑Sure.

PN1033

Paragraph 16 of your statement, you talk about the demographic of the pharmacy being different in a rural area, do you see that?‑‑‑Yes.

PN1034

I gather from your work history you've always worked in rural areas?‑‑‑Yes - rural in most, yes.

PN1035

And small and large country towns?‑‑‑Yes, right.

PN1036

The demographics of a rural area in terms of age, ethnic background and social economic customers you say are diverse?‑‑‑Yes.

PN1037

Would you agree that it has been diverse in every area that you've worked in?‑‑‑Yes.

PN1038

And that's the nature of being a pharmacist, that you're dealing with different people from different backgrounds, both social and economic, ethnic or age?‑‑‑Yes.

PN1039

And your training prepares you for dealing with people from different walks of life?‑‑‑Yes.

PN1040

When you say in paragraph 16, "patients with special requirements are more time‑consuming", you're not saying that there aren't patients with special requirements at other pharmacies; you're just talking about your own experience here?‑‑‑Well, like you said, all the pharmacies have different demographics, so it just depend on which area.

PN1041

So I understand, you're saying, for example, a patient who had limited English is someone with special requirements, that's right?‑‑‑Yes.

***�� CARDIN LE�� XXN MR SECK

PN1042

What I want to put to you is that that's not unique to rural areas or any particular area. It's going to be a situation which is faced by nearly every pharmacist where they work. There's going to be people from different socioeconomic and age profiles, and that's a skill which you deploy in your capacity as a pharmacy in any location?‑‑‑Yes.

PN1043

You say in the bottom half of paragraph 16 that this leads to a stressful environment because there are more tasks and people walk in and start to line up, which means that your workload is increased. Do you see that?‑‑‑Yes.

PN1044

So the workload that you have is a function of in part the staffing at the pharmacy, do you agree?‑‑‑The what, sorry?

PN1045

The staffing?‑‑‑The staffing?

PN1046

Yes?‑‑‑Yes.

PN1047

Do you agree with that?‑‑‑In some ways, yes.

PN1048

In fact, you say that in the last sentence: "Availability of staff is also kept to a minimum?"---Yes.

PN1049

So that's a decision made by the individual pharmacist as to the number of staff they have to service the customers on any particular shift, do you agree?‑‑‑Yes - well it's not a decision of the pharmacist. It's the decision of the owners of the pharmacy.

PN1050

Yes, that's what I meant to say - the owner of the pharmacy, that's right?‑‑‑Yes. I'm only an employee pharmacist, so I don't have that power to say how many staff I have and all that.

PN1051

Would it be fair to say that the owners of the pharmacies that you've worked at have had different approaches to staffing, depending on the level of demand on each particular shift?‑‑‑Yes.

PN1052

So there would have been some pharmacies for whom you worked where the staffing was higher relative to the demand for or the patients who came in the door compared to other places where you worked?‑‑‑I guess so, yes.

***�� CARDIN LE�� XXN MR SECK

PN1053

You talk about new work which had not been previously done when you commenced practising as a pharmacist?‑‑‑Mm‑hm.

PN1054

Let me talk to you about a few of the - one you talk about is impact of quality use of medicines, do you see that?‑‑‑Yes.

PN1055

Would you agree that the impact of the quality of use of medicines is something you've always advised on from the time that you were a pharmacist in 2010?‑‑‑Yes.

PN1056

And the ageing population and co‑morbidity, that is something which has existed as an issue since 2010?‑‑‑Yes.

PN1057

Increasing number of medicines, now in your experiences, by the progress of science there's always an increasing number of medicines to deal with ailments, would you agree with that?‑‑‑Yes.

PN1058

So these issues have been consistent since your time as a pharmacist, do you agree?‑‑‑Yes.

PN1059

You said beforehand you were required to attend CPD courses. I think you mentioned that in answer to one of my earlier questions?‑‑‑Yes.

PN1060

And the costs associated with attending the course fell upon you, that's right?‑‑‑Yes.

PN1061

When you negotiated your individual flexibility agreement with your employer, did you put that as part of the claim that you wanted to have reimbursed by your employer?‑‑‑Yes, I have.

PN1062

As part of negotiations, your employer agreed or disagreed to reimburse you?‑‑‑Disagreed.

PN1063

But that was something you sought to negotiate with the employer, they disagreed, but I think, as you said, you were happy with the individual flexibility agreement and you nonetheless signed it, correct?‑‑‑Well, I don't have a choice, do I? If I want the job I have to agree to what is offered.

***�� CARDIN LE�� XXN MR SECK

PN1064

Well, you said beforehand that you signed the agreement because you were happy to sign it?‑‑‑Yes.

PN1065

So when you say you were happy to sign it, no one is forcing you to sign the agreement; it's part of the negotiation for receiving the above award rates in exchange for the job, do you accept that?‑‑‑That's correct, yes.

PN1066

And the time you say you lost attending CPD courses - - -

PN1067

VICE PRESIDENT HATCHER: Just before we go on, Mr Le, this agreement you're talking about, was that entered into before you actually started employment?‑‑‑Yes.

PN1068

I don't think it can be an IFA then. I suspect it may be more in the nature of an annualised salary agreement.

PN1069

MR SECK: All right. Mr Le, do you have copies of your IFA?‑‑‑IFA?

PN1070

Yes?‑‑‑No, not on me, no.

PN1071

No, but you have copies with you in your records?‑‑‑Yes.

PN1072

You signed an IFA during your employment with Len Wade Pharmacy, because I think you said you got promoted from pharmacist then to pharmacy in charge and then pharmacy manager, correct?‑‑‑Yes, correct.

PN1073

So you signed an individual flexibility agreement every time you moved up into a new position?‑‑‑Yes, they're drawn up, a new contract, yes.

PN1074

In relation to the individual flexibility agreement with your current employer - I think the Vice President asked you when you actually signed that - did you sign that before or after you commenced employment?‑‑‑Before.

PN1075

Are you paid an annualised salary under the current agreement or is it an hourly rate?‑‑‑An hourly rate.

PN1076

Now, your CPD, CPD requirements came into effect in recent years, that's right?‑‑‑That's right.

***�� CARDIN LE�� XXN MR SECK

PN1077

Before the compulsory CPD requirements came into effect, did you an interest in learning about new topics, topics relevant to your job, even though it wasn't compulsory?‑‑‑Yes, I do read about it.

PN1078

And you attended courses and undertook training to improve your skills to advance your career, do you agree?‑‑‑Yes.

PN1079

As part of doing that, you paid for that out of your own pocket, that's right?‑‑‑That's right.

PN1080

And that's because you saw that as a necessary aspect of you progressing your career as a pharmacist, do you accept that?‑‑‑Yes. It's more attractive for employment.

PN1081

Yes, and so the fact that there are compulsory requirements to undertake CPD hasn't really changed, at least your desire to undertake further training paid out of your own pocket?‑‑‑Yes - in my case, yes.

PN1082

Yes, in your case, right. In paragraph 18, you say:

PN1083

Since my undergraduate degree I've had to undertake further training to perform many new services provided by my pharmacy.

PN1084

The further training that you undertook, was that voluntary?‑‑‑No, it was necessary, like the down-scheduling and up-scheduling of S4 and S3 drugs, for example, the recent one is the codeine.

PN1085

So I understand that, the drugs change from a doctor‑prescribed drug to something which a pharmacist or pharmacy‑only prescribed drug, right?‑‑‑Right.

PN1086

And that's down-scheduling?‑‑‑Yes.

PN1087

So what you're learning is when those drugs get moved from one schedule to another schedule, the proper use of those medicines, that's right?‑‑‑Yes.

PN1088

VICE PRESIDENT HATCHER: Mr Le, am I right in saying that codeine was in fact up-scheduled?‑‑‑It is up-scheduled, sir, yes, where the (indistinct) is down-scheduled and the (indistinct) eye drops is down-scheduled.

***�� CARDIN LE�� XXN MR SECK

PN1089

MR SECK: And up-scheduling and down-scheduling occurs on a regular basis in your time?‑‑‑Yes, yearly or most yearly.

PN1090

So this is a regular part of your job, right, having to understand new drugs as they move between schedules?‑‑‑Yes.

PN1091

And it's also a necessary part of your job that when new medications come up that you learn about those medications and the proper use of those medications?‑‑‑Yes, correct.

PN1092

And that in fact would be an inherent feature of being a pharmacist?‑‑‑Correct.

PN1093

No further questions.

PN1094

VICE PRESIDENT HATCHER: Any re-examination, Ms Knowles?

PN1095

MS KNOWLES: No re-examination.

PN1096

VICE PRESIDENT HATCHER: Thank you for your evidence, Mr Le. You're excused and you're now free to go, which means you can simply hang up the phone?‑‑‑Thank you, sir.

<THE WITNESS WITHDREW�� [11.41 AM]

PN1097

VICE PRESIDENT HATCHER: We might take a short morning tea adjournment before we start with the next witness. We'll now adjourn.

SHORT ADJOURNMENT�� [11.41 AM]

RESUMED�� [12.06 PM]

PN1098

VICE PRESIDENT HATCHER: Ms Knowles, is Mr Yap the next witness?

PN1099

MS KNOWLES: Yes.

PN1100

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

***�� CARDIN LE�� XXN MR SECK

PN1101

MR YAP: My name is Leon Wai Hon(?) Yap, and my address is (address supplied).

<LEON YAP, AFFIRMED�� [12.06 PM]

EXAMINATION-IN-CHIEF BY MS KNOWLES�� [12.07 PM]

PN1102

VICE PRESIDENT HATCHER: Ms Knowles?

PN1103

MS KNOWLES: Mr Yap, have you prepared a statement for these proceedings?‑‑‑I have.

PN1104

Is that a statement dated 18 December 2017 which is 11 pages long and 35 paragraphs long?‑‑‑That's correct.

PN1105

If I can you to paragraph 9 of that statement?‑‑‑Yes.

PN1106

You see that you're paid per the Health Practitioners and Dental Officers (Queensland Health) Award - State 2015; with the correction after "Award" instead of that word "Agreement 2016", is that correct to make that paragraph correct with that correction?‑‑‑Correct.

PN1107

And with that correction, are the contents of your statement true and correct?‑‑‑They are correct, yes.

PN1108

I tender that.

PN1109

VICE PRESIDENT HATCHER: The statement of Leon Wai Hon(?) Yap dated 18 December 2017 will be marked exhibit 8.

EXHIBIT #8 WITNESS STATEMENT OF LEON YAP DATED 18/12/2017

PN1110

MS KNOWLES: No further questions.

PN1111

VICE PRESIDENT HATCHER: Yes. Mr Seck?

PN1112

MR SECK: Thank you, your Honour.

***�� LEON YAP�� XN MS KNOWLES

CROSS-EXAMINATION BY MR SECK�� [12.08 PM]

PN1113

MR SECK: Mr Yap, I am the barrister representing the Pharmacy Guild of Australia. I'm just going to ask you a few questions about your witness statement. Do you have a copy of your witness statement with you in the witness box? Can you hear me, Mr Yap?‑‑‑Yes.

PN1114

Sorry, tell me if you can't hear me. Do you have a copy of your witness statement in the witness box, Mr Yap?‑‑‑Yes, I do. I can hear you.

PN1115

Good. Just looking at your career history in paragraph 7 of your witness statement, Mr Yap, it begins in 1999 as the pharmacist in charge at Tungon Chemmart Pharmacy - - -

PN1116

COMMISSIONER SPENCER: Tugun.

PN1117

MR SECK: Sorry, Tugun - I'm showing my lack of local knowledge - I am grateful, Commissioner - Tugun Chemmart Pharmacy. Do I gather you were pharmacist in charge from the very time you started at Tugun Chemmart Pharmacy?‑‑‑I wouldn't say that. The owner of the store was there initially, but there were periods definitely - I'm not sure at what stage I would have been in charge, just by myself, but it wouldn't have been straight away, but definitely in 1999 I acted as the pharmacist in charge.

PN1118

You did an internship before you completed your degree. Where did you do your internship, Mr Yap?‑‑‑I did my pre‑registration or internship at the same pharmacy.

PN1119

So there was a progression from being an intern to a pharmacist, then to a pharmacist in charge at Tugun?‑‑‑Yes, that's correct.

PN1120

I'll come back to questions about your internship program, but you did progress to becoming, quite shortly after you graduated, proprietor at Border Chemmart Pharmacy and Kirra Beach Chemmart Pharmacy between 2001 and 2005, that's right?‑‑‑That's correct.

PN1121

***�� LEON YAP�� XN MS KNOWLES

***�� LEON YAP�� XXN MR SECK

Was that on your own or was that owned with other proprietors?‑‑‑That was in partnership with my former employer at Tugun Pharmacy. So we went into partnership together.

PN1122

Would you agree that's a reasonably quick progression to becoming a proprietor, basically a two‑year period, compared to perhaps your colleagues?‑‑‑I think at the time a lot of my colleagues fairly quickly went into ownership. So it was a fairly quick progression, but yes, a lot of my classmates from university went into ownership fairly well straight away as well.

PN1123

So you would agree that the progression to becoming an owner is really a matter of opportunity which presented itself to you, because it just happened to be that the owner of Tugun Chemmart Pharmacy invited you to become a proprietor in other pharmacies shortly after you commenced?‑‑‑At the time, yes, opportunity was - definitely. The pharmacies were a lot more affordable in those days and the ability to get credit to buy a pharmacy was a lot easier. The wholesalers would give guarantees in those days. But yes, it was a fairly quick progression.

PN1124

Were those new pharmacies which were established?‑‑‑No, they were established pharmacies.

PN1125

You decided after a four‑year period to cease being a proprietor and work in Ireland. Was that just so you could experience different things overseas?‑‑‑That was definitely part of it. I was only fairly young at the time. At the time there was a reciprocal agreement between the two countries, so a pharmacist could practice in Ireland and the UK with fairly easy sort of transition, and it was closing off at that point in time in 2005. So it was a combination of definitely wanting to experience travel and experience something different, as well as I could say that maybe I'd just had enough of being an owner at the time.

PN1126

That's one thing I want to explore with you, Mr Yap. When you said you had enough of being an owner, what was your experience as an owner? Was it a difficult process in terms of owning and operating a pharmacy?‑‑‑Sorry, the volume is - I can't hear you now.

PN1127

Pardon me. Let me ask you a general question. What was your experience in owning a pharmacy? Did you find it an easy process or a difficult process? How would you have described it?‑‑‑I think an owner was quite stressful. You've got the business to worry about as well as if you're the sole pharmacist, as well as trying to practice as a pharmacist as well professionally.

***�� LEON YAP�� XXN MR SECK

PN1128

So the balancing of each of those particular roles and functions was not an easy one for you?‑‑‑I enjoyed it, but it takes its toll.

PN1129

As an owner you were obviously in charge of ensuring that the pharmacies ran at a profit, and did you make a profit during your time as a pharmacy proprietor?‑‑‑I think the pharmacies made profits. We did make some losses, but we paid the bills. It was a while ago, sorry.

PN1130

That's all right. The reason why I'm keen to explore it with you, Mr Yap, is just to understand that - you know, I think one of the issues which we're looking at is the difficulty in people obtaining opportunities to become proprietors and the reasons why people do become proprietors. I just thought looking at your example it may seem unusual why you left becoming a proprietor, and you've given one of the reasons, which is - - -

PN1131

VICE PRESIDENT HATCHER: Is there a question here, Mr Seck?

PN1132

MR SECK: Yes. The question I wanted to come to, Mr Yap, is was one of the reasons why you decided to stop becoming a proprietor is because the business pressures and the fact that it was making losses from time‑to‑time wore you down?‑‑‑I think the business pressures was part of it. I mean, there was a bit of a partnership breakdown as well, if you want to say. So there were multiple factors.

PN1133

Let me move on to another topic. You set out your undergraduate studies in paragraphs 13 to 15 on page 3 of your statement, and one of the things you set out in your undergraduate degree that you did was patient counselling and basic diagnosis skills. Do you see that in both paragraph 13 and paragraph 15?‑‑‑Yes.

PN1134

In terms of patient counselling, what was taught to you as part of that degree?‑‑‑I think basic counselling would have been just to explain to the patient how to take medication, so you know, whether that's taken once a day, twice a day, that sort of thing. You give some information on some side effects if they are relevant as well. So that was then.

PN1135

Would that, in terms of explaining to patients the proper use of medication and side effects, include communication skills?‑‑‑Yes, we had to have some communication skills.

***�� LEON YAP�� XXN MR SECK

PN1136

But that was taught as part of the undergraduate studies?‑‑‑We did counselling classes, so we were taught to talk to the customers. I think today we would definitely be talking to them a lot more and asking more deep questions and more patient‑(indistinct) questions. So we were taught how to talk to customers, yes.

PN1137

And in being taught how to talk to customers, part of that would be to ascertain, for example, the health history of the patient and the medications that they were taking?‑‑‑Yes, I think we were taught to ask if someone was on other medications.

PN1138

But you were also, in determining whether or not there's proper use of medicines, you were also taught if you had to ask background questions about the particular health status of the patient?‑‑‑I can't remember. Possibly, we might have been taught that, that there may be other medical conditions, other medications they were taking, but nowhere near as sort of comprehensive sort of questioning that we would be asking today.

PN1139

Right, and I'll come back to that, Mr Yap. I just want to focus in terms of your undergraduate studies. You were also taught about - I mean, obviously in advising about medication, one thing you would need to ascertain is the general health of the particular patient, would you agree?‑‑‑In what context do you mean their general health - are they well or - - -?

PN1140

Yes, well let me put it in a different way. If you're advising or in counselling a patient as to the proper use of medications, one of the things which would be necessary for you to know would be whether or not the patient was suffering from any particular illnesses or ailments, would that be correct?‑‑‑I think that would be relevant. More often than not we would focus on, at the time, focus on the medication, perhaps assuming that the doctor had already found out these problems and had made the decision to prescribe that medication. So our job would have just been to tell that patient how to use that medication. We would ask - I mean, you'd ask if they suffered from any other conditions, I would think, but it wouldn't be that in‑depth compared to today. At the time there were obviously both - there were, as I understand it, schedules in the poison standard that apply. That was something which applied during the time when you studied at university - poison schedules, yes, the poison schedules existed.

PN1141

And therefore there would have been times when you wouldn't have doctors prescribing the medicines if - it could be over‑the‑counter medicines that you were providing the counselling to patients on, would that be fair?‑‑‑Yes. As I said in my statement, we would definitely sell over‑the‑counter medications to patients in 1999. I think the amounts of over‑the‑counter medications have definitely increased since those times, and the complexity of the medications as well.

***�� LEON YAP�� XXN MR SECK

PN1142

Looking at paragraph 15, you've got you also studied or covered in your studies basic diagnosis skills. I gather from that what that involved was asking questions and making observations of patients to see whether or not you can make a diagnosis of particular ailments or illnesses?‑‑‑Yes, I would say that's true. If someone asks for medication for a cough or a cold, or just asked for a product by name, we would ask that patient a couple of questions about what they're suffering, is it for them, have they tried anything before, and then judging by the answers given to try to choose the appropriate product for them.

PN1143

So you would agree that even at university you had already been taught at least some skills as to the kind of questions to ask in order to obtain the relevant information so that you could diagnose a particular issue and ascertain the appropriate medicine to dispense, whether that be through a doctor's prescription or over the counter?‑‑‑I think we were definitely taught, for over‑the‑counter medications, definitely taught some basic diagnostics, but very limited in their scope in terms of which conditions we could diagnose, if we wanted to call it diagnosing. In terms of prescription medications, I'm not sure if we were taught to diagnose - we were obviously taught what the medication is generally for, but in terms of finding out the exact diagnosis of the patient, you would only get that if you asked the patient what the medication was for. We don't have access to any doctor's notes or anything like that. So yes, we were taught some basic diagnostic skills, but I think definitely practising today, your diagnostic skills would have to be far greater and far better than they were, and the amount of medications and conditions you're expected to diagnose are far greater.

PN1144

Well let's explore that now, Mr Yap. In paragraph 20 of your statement you refer to the situation now compared to when it was when you started in 1999. You said you're required now "to be trained and competent to diagnose, treat as appropriate or refer to a doctor for the above conditions as well as" - and then you list a whole lot of conditions. Would it be fair to say what you're saying there is that the range of conditions has expanded and therefore the diagnosis and treatment or referral of patients in respect of those ailments has expanded as well?‑‑‑Yes, I think definitely the amount of conditions that a pharmacist is asked to diagnose and treat across the counter has increased. The range of medications available to treat conditions has increased, and I would also argue the complexity of the medications has increased. I mean, you know, things that were previously prescription only, they may have interactions and other precautions, and we're expected to know these and apply them when we're treating a patient.

PN1145

But would it be fair to say that since you've started in 1999, Mr Yap, it has always been the case that there has been new conditions arising, new medications arising and complexities arising out of those conditions which you've had to address, and that's just inherent in the nature of being a pharmacist, because scientific advancement means these things change?‑‑‑I'd say more - a lot of these conditions already existed in 1999, but previously they would have been treated by the doctor and we would purely be dispensing a prescription relating to those conditions. With the down-scheduling of different medications, the onus has been moved onto the pharmacist to be able to diagnose and treat a range of these conditions.

***�� LEON YAP�� XXN MR SECK

PN1146

During your time as a pharmacist from 1999, there's been medicines which have been up-scheduled and medicines which have been down-scheduled, would you agree?‑‑‑There's a lot more medications that have been down-scheduled than up-scheduled.

PN1147

But both have occurred?‑‑‑Yes, both have occurred.

PN1148

And in down-scheduling - let's just deal with down-scheduling at the moment - what's that meant is that you've had to deploy your skills to a different range or a broader range of conditions as a result?‑‑‑I think I've been required to deploy skills as well as learn new skills in diagnosing - - -

PN1149

When you say learn new skills, the new skills would include understanding more about those medical conditions, yes?‑‑‑Yes, I'd say yes, definitely understanding more, and how to - - -

PN1150

How to diagnose those conditions?‑‑‑Yes, how to diagnose those conditions.

PN1151

And the appropriate and judicious use of medication in addressing those conditions?‑‑‑Yes.

PN1152

You would agree that's a deployment of your existing skillset but done to a different range of conditions which you've had to educate yourself on?‑‑‑I think, as I said, we did learn some basic diagnostic skills, but I think we've had to expand those skills during my working period.

PN1153

The expansion of those skills means that you've had to do some further training to understand that, so that would be partly your own reading and attending some formal courses, would that be correct?‑‑‑I think, yes, definitely reading. I mean, there have always been pharmacy journals that would give some basic information about new drugs or perhaps give some information on medications that had been down-scheduled. Courses - yes, there's CPD courses that I've attended.

PN1154

Dealing with reading, you say there's journals that you read, but there's also a database known as MIMS, which you must consult from time‑to‑time, that's right?‑‑‑Yes. Yes, MIMS is the list I guess, or yes, I guess a database of all usually registered medication products.

PN1155

You've used that since 1999?‑‑‑Use MIMS, I think I use some - I forget what I used in the past.

***�� LEON YAP�� XXN MR SECK

PN1156

You used some database? It may not be MIMS but it was something similar to MIMS?‑‑‑It wouldn't have been databases in those days. It would have been textbooks, very large textbooks.

PN1157

So the technology has made the information much more accessible, would you agree?‑‑‑Technology has made the information - yes, more accessible.

PN1158

And quicker to find?‑‑‑You've still got to look for something - I mean, if you had the information in a textbook you'd obviously - most of them are A to Z so you could find the (indistinct).

PN1159

And in a database you would type in the particular condition and the information would be spat out on the screen?‑‑‑Well, you'd type in - if you were typing in a medication, yes, it would give the information on screen. If you typed in a condition - it depends on the data, but yes, you could type in a condition and get some information.

PN1160

You said beforehand you would also keep up‑to‑date by reading journals. You've read journals since your time as a university student all the way to now to update yourself as to new medications and the proper use of those medications?‑‑‑I've definitely read - yes, I've read journals, I've read information leaflets that the companies would provide if a new drug has been added to the list. There was no compulsion to do such a thing, but I would have done some of those things.

PN1161

Whilst there wasn't any compulsion, in order to practise as a competent pharmacist you obviously had to keep up‑to‑date with these issues, so you obviously felt it necessary in order to practise as a professional pharmacist to read up in journals and other publications to make sure that your knowledge was up‑to‑date?‑‑‑Yes, I'd say I would have - if a new medication had been released, yes, I would have read a little bit about it just to find out what it was and how it worked.

PN1162

You said you attended courses since 1999. As you understand it, CPD has only become compulsory in recent years?‑‑‑Yes. I forget the exact dates. I put it in my statement.

PN1163

That's all right?‑‑‑I wouldn't have attended a lot of courses. I think the drug companies may have put on a few information sessions every now and then, which I may have attended, but I never attended any - I don't think I ever really attended any courses after my pre‑registration year until fairly recently, until compulsory CPD was introduced.

***�� LEON YAP�� XXN MR SECK

PN1164

But you did what was necessary to read up and attend those pharmaceutical company sessions to ensure that, at least in your view, your knowledge was adequate to perform your job professionally and competently?‑‑‑Yes. If a new medication was released and if I felt I wanted to have a decent knowledge of that medication, I would definitely have read up on it.

PN1165

You refer to quality standards which were introduced in 2000/2001 in paragraph 26 of your statement?‑‑‑Yes.

PN1166

You were aware before 2000 there were professional standards that applied?

PN1167

MS KNOWLES: Objection. Can there be some more specificity for this question, and what standards?

PN1168

VICE PRESIDENT HATCHER: Professional standards. I'll allow the question.

PN1169

MR SECK: Were you aware the professional standards applied prior to 2000?‑‑‑I think there were some professional standards. I'm not 100 per cent sure.

PN1170

You learnt that there were technical and professional standards which applied to your job in your university degree?‑‑‑I'm not sure if - we would have been obviously told or taught how to behave and what professional behaviour would be. I can't recall if there was any codified professional practice standards at the time. We would have been taught to adhere to the Health (Drugs and Poisons) Regulations in terms of legalities and supply and storage, legalities of prescriptions. I can't recall if there was actual practice standards at the time or whether they were just assumed.

PN1171

So whether or not there were practice standards or they were assumed, you certainly understood that as part of practising as a pharmacist there were standards and expectations placed upon you in terms of - - -?‑‑‑I think there's definitely - - -

PN1172

Keep on going, sorry?‑‑‑I was going to say I think definitely you were expected to act in a customer's or a patient's best interest and act professionally, but in terms of the quality care standards, that relates to not only practice standards; I think there's a whole variety of other things that it relates to in terms of business practice and particular standards for particular services and other things, which I don't think would have existed in 1999.

***�� LEON YAP�� XXN MR SECK

PN1173

I think you said you weren't sure that professional standards existed. Is it your evidence that they weren't in existence or you're just not sure?‑‑‑I'm not sure.

PN1174

You also referred - - -

PN1175

VICE PRESIDENT HATCHER: I'd like to just speak to you about this, Mr Seck. I thought GM24 was the first at least consolidated set of professional practice standards issued by the PSA?

PN1176

MR SECK: GM - sorry, your Honour - - -?

PN1177

VICE PRESIDENT HATCHER: GM24 of Mr March's reply statement.

PN1178

MR SECK: I think that's right. Can I then move on, Mr Yap, to your evidence on dose administration aids? They're now currently funded under 6CPA, as you understand it, that's correct?‑‑‑Yes.

PN1179

Were they being provided by the pharmacies you were working at prior to the introduction of 6CPA?‑‑‑Prior to 6CPA?

PN1180

Yes?‑‑‑Yes, definitely they were being provided prior to 6CPA.

PN1181

And you say it has been introduced to pharmacists' practice since you registered - this is paragraph 27 - do you see that?‑‑‑Yes.

PN1182

You're only referring to your experience in your pharmacies, right, that DAAs had been introduced, not that it hadn't been introduced in other pharmacies prior to your registration?‑‑‑I don't - yes, I guess it's just my evidence. I don't know what would have been provided everywhere at the time.

PN1183

Go to paragraph 28 of your statement. You refer to opioid replacement had occurred in community pharmacy before you started practising, but it was only methadone syrup that was available. From what I can gather, whilst opioid replacement was available, it was really the replacement medication which was different, is that right?‑‑‑Yes. There was, as I stated, there was only - as far as I can recall - there was only methadone syrup available, which - - -

PN1184

Sorry, go on?‑‑‑I was going to say it's still available now, plus there's another type of methadone as well as Buprenorphine, which is a sublingual film.

***�� LEON YAP�� XXN MR SECK

PN1185

But whether or not it's methadone syrup or other opioid replacements, you still have to give appropriate advice as to whether or not it's appropriate for that particular patient, correct?‑‑‑Sorry, give advice to - - -?

PN1186

To the patient in terms of the opioid replacement, whether that be methadone syrup or some other medication?

PN1187

VICE PRESIDENT HATCHER: Is that prescribed by a doctor which one is used, or do you decide that?‑‑‑No, they're definitely - they're all prescribed by the doctors. They're Schedule 8 medications, so they're highly - they're controlled drugs. It's all prescribed by a prescriber and it's the prescriber who determines which medication is used for a particular patient.

PN1188

MR SECK: My question was, Mr Yap, and I may not have expressed it properly, is that whether or not it's methadone syrup or some other medication which has been prescribed by a medical practitioner as an opioid replacement, you still have to give advice as to the proper use of that particular medication, would you agree?‑‑‑When I first started practising, I don't think there was any standards about the supply or the information required to give to patients. It was very cursory, as far as I can recall; like, you just basically gave it out and that was it. Now they developed some opioid replacement guidelines - I'm not sure when, but it was relatively recently - which really made it much more stringent, or for lack of a better word, how to actually administer, how to administer the program, give the medication to the patients, what to look out for, what behaviours or symptoms to observe if a patient is under the influence of other medications prior to dosing. So that's more what you have to do now. Back in 1999, the patient would present to the pharmacy, you would give them their dose and then say goodbye.

PN1189

When you say they would just present to the pharmacy and you would give them their dose, you would still obviously perform your role as a pharmacist in giving appropriate advice and counselling to the patient about the particular opioid and its use, would you agree?‑‑‑Well, I think - no, I think in 1999 the decision of which medication to give was determined by the doctor, which it still is today, but there wasn't a lot of input from the pharmacist. The pharmacist was, as far as I can recall, the patient would come to a particular pharmacy where you held the prescription for that supply; you could identify the patients, because they come every day - you would identify the patient and then give them their dose, make sure that they drank it, and then that was it. Not a lot of interaction in terms of advice and anything really. Today obviously you would follow the guidelines, you would identify the customer, you'd determine what sort of state they're in, if they were exhibiting symptoms of drowsiness or being intoxicated. You'd have to sort of determine if it would be appropriate to give the dose that's scheduled for that day. If it's not, you'd contact the prescriber and tell them, and then you'd have to tell the patient that they're not in a fit state to receive their medication.

***�� LEON YAP�� XXN MR SECK

PN1190

You may not know the answer to this, Mr Yap, and tell me if you don't. Were you aware that there were professional practice standards which were promulgated in May 1999, which dealt with amongst other things the provision of drug information?‑‑‑I can't recall.

PN1191

Do you remember following any particular standards in 1999 in relation to the provision of drug information when you were providing the opioid replacement to patients?‑‑‑I don't recall any specific standards, no.

PN1192

You also deal with in your statement, Mr Yap, that as part of the successive CPAs there are new services which are provided, including, for example, DMMRs - Domiciliary Medication Management Reviews - now known as Home Medicines Reviews as well as MedsChecks, that's right?‑‑‑Yes.

PN1193

I want to put to you that what's involved in - let's use MedsChecks as an example - is really the deployment of the same skills, or the skills that you were trained in as a pharmacist and which you've used since 1999, that is, obtaining an understanding of the medication of the patient and then advising and counselling on the appropriate use of medication for that patient. Would you agree with that?‑‑‑No, I think we were trained to know about what a medication was, how it worked, and as I said, basically to tell patients how to take something. I don't think we were trained very well in taking medication histories very well, or anywhere near as comprehensively as you're trained now. I think the MedsChecks service also requires you to be able to determine whether a patient's medications - if they're on five or six medications - to be able to examine whether any of those medications interact with each other, what specific adverse effects they might cause the person, how they interact with the patient's other medical conditions. I think that's more skills that have been developed recently or throughout my career, rather than what I was trained on, I believe.

***�� LEON YAP�� XXN MR SECK

PN1194

What I want to put to you is that whilst you may deploy those skills much more nowadays, those were skills which you have always had as a pharmacist and you learnt as a pharmacy student at university; it's just that it has become more formalised through the provision of these programs as a result of subsidies provides under the CPAs. Do you agree?‑‑‑No, I think we were trained mostly on medications themselves, to focus on the medication, to focus on the prescriptions. In those days, basically all prescriptions were hand‑written, so a lot of what you needed to do was to be able to translate what the doctor had written, process the prescription, label the medication and then give basic counselling on how to take something. I think the more in‑depth, more holistic, approach that we make now determining what other medications that patients are taking, what other medical conditions they have, what is their sort of health picture at the moment, what medication information they want, or need, what other complementary medications they might be taking, I think all these are all new skills that we've developed over the years. I honestly don't think it was part of our training.

PN1195

I want to put to you that what you've done is overplayed what is now required, and that what has always been required as part of your profession as a pharmacist is to ask questions about the health situation and medication being taken by patients, and to advise and counsel on the adverse impacts of that medication and how it may interact with other medications. That has always been part of your job.

PN1196

VICE PRESIDENT HATCHER: I think there are two propositions there, one that the witness has overplayed it, and two, it has always been part of his job.

PN1197

MR SECK: I might put it to you as separate propositions, Mr Yap. Do you agree with my proposition that you're seeking to overplay the skills which are required in conducting a MedsCheck?‑‑‑I don't believe so. I've conducted MedsChecks. I know what you have to ask, and what sort of information you need to convey to the customer. It's a far more comprehensive interaction than the basic counselling we were given in 1999 when I first started practising.

PN1198

And I want to put to you that the skills that you're deploying in performing a MedsCheck is exactly the same as what you would have done as a pharmacist back in 1999. All that has changed now is the duration of the interaction with the patient and that it's more formalised, because it's done pursuant to funding provided under the CPAs?‑‑‑No, I think that what we were taught at university and the way we practise in 1999 was to focus on the medication, to focus on delivering - giving information to a customer, not really on determining the full health picture of that patient. I think performing a MedsCheck takes a considerable amount of time. It takes about 30 minutes, 45 minutes or so. You just would not have had that sort of length of time to talk to a patient or a customer back in the day, back in 1999. So I think the two‑way interaction, it's giving information as well as receiving, and it's an interaction between the customer asking you questions and being able to formulate an answer to give them. I think those skills are definitely skills that we've developed since I was first trained.

PN1199

Two more questions, or line of questions, Mr Yap. In paragraph 33 of your statement, you also refer to the fact that the jobs that you're performing are often performed by one pharmacist's pharmacies, and that you're often being the sole pharmacist working on a particular day. It hasn't always been the case that you've worked in one pharmacist's pharmacy, that's right? It depends on staffing and the size of the pharmacy?‑‑‑Yes, some definitely. I was working in pharmacies with multiple pharmacists and pharmacies just as the sole pharmacist.

***�� LEON YAP�� XXN MR SECK

PN1200

And that obviously differs from pharmacy to pharmacy that you've worked at?‑‑‑Yes.

PN1201

And obviously as a former proprietor of a pharmacy, that is a matter which is controlled by the pharmacy owner?‑‑‑Yes, true, yes - - -

PN1202

So the workload is going to vary depending on all those variables, would you agree?‑‑‑Yes, definitely. I mean, if you're the only pharmacist on, then all the workload is on your shoulders. If the owner has employed or rostered on two pharmacists, then obviously the total amount of work is shared between the two of you, but it doesn't make the actual difficulty of the work any easier, if that makes any sense.

PN1203

Lastly, you're a committee member of Professional the Pharmacists Australia division of APESMA, is that so?‑‑‑That's correct.

PN1204

When I was looking at the Professional Pharmacists website, there's a story which is under your name, which refers to your reasons for joining APESMA. Are you aware of that being published on the internet, on the APESMA website?‑‑‑Possibly. I'm not sure what it states.

PN1205

I'll read out a part to you and tell me if this rings a bell. It says:

PN1206

When the pharmacy division of Professionals Australia relaunches Professional Pharmacists Australia with a fresh plan to fight for employee pharmacist's wages and conditions, I felt compelled to join. I believe that PPA is the only pharmacy organisation that truly represents the interests of non‑pharmacists and I learned quickly that they already have rungs on the board when it comes to negotiating fair wage agreements with some pharmacy groups.

PN1207

Does that ring a bell?‑‑‑Yes, it does.

PN1208

Were you aware that there was something on the website published from you saying words along those lines?‑‑‑I'm happy if they published that. They are the reasons why I joined.

***�� LEON YAP�� XXN MR SECK

PN1209

When you say you learned quickly they already have rungs on the board when it comes to negotiating fair work agreements with some pharmacy group, that was based on information provided to you by APESMA, is that right?‑‑‑Yes, I think so. I think they told me that they had at least one agreement with - I think it was Friendly Society Pharmacy group.

PN1210

When you say they already have rungs on the board when it comes to negotiating fair wage agreements, you're referring to the one agreement with National Pharmacies?‑‑‑Yes, I think there was that one. There possibly was a private hospital one at the time as well. There's a HPS Pharmacies, I think.

PN1211

From what has been published and what you've said here and what has been published on the website, I gather that one of the things APESMA is seeking to do is to negotiate collective agreements or enterprise agreements with pharmacy groups, that's right?

PN1212

VICE PRESIDENT HATCHER: What, that he knows that you gather that?

PN1213

MR SECK: Sorry. Let me put it a different way. You say in your statement, "I learned quickly that they already have rungs on the board when it comes to negotiating fair wage agreements with some pharmacy groups", and you're, as I understand it, seeking to promote the Professional Pharmacists Australia division of APESMA. So would it be fair to say that one of the things APESMA is trying to do is to promote enterprise bargaining negotiations with the pharmacy groups?‑‑‑I would say yes, they're definitely trying to promote EBAs. Whether they're having a great deal of success or not is - it's very difficult to get groups of pharmacists to put their necks on the line, if you want to say that, to try and negotiate these agreements. A lot of pharmacies are single pharmacist enterprises or there might only be one pharmacist employed, and it's quite difficult to - you know, obviously if that pharmacist feels their job is in jeopardy if they ask for an EBA or a pay rise then it's difficult for that to occur. But yes, I think APESMA is pursuing those avenues.

PN1214

As a committee member of the Professional Pharmacists Australia division of APESMA, are you privy to details as to enterprise bargaining negotiations which are being sought with pharmacy groups?‑‑‑Actual ones that are being pursued or - - -?

PN1215

Actual ones or ones in the past?‑‑‑We're given an industrial update at our - we have a monthly meeting and we're given an industrial update, so from time‑to‑time we might be updated on a particular discussion that's occurring.

***�� LEON YAP�� XXN MR SECK

PN1216

And so as part of being updated on the committee, you are aware of from time‑to‑time efforts made by APESMA to enter into enterprise agreements with employers in the pharmacy industry?‑‑‑Yes. I mean, at the moment, as far as I know, there's the two - the National Pharmacies agreement - we were sort of given updates on how those negotiations were going - yes, I think we're given some information, not the detail.

PN1217

Given that you've spoken on behalf of APESMA on the website promoting one of the benefits of being - - -

PN1218

MS KNOWLES: Well, actually he didn't say that he'd spoken on APESMA on the website - he acknowledged that he'd said those things and he said he was happy for APESMA to publish it.

PN1219

MR SECK: All right. Given that you were happy for APESMA to publish on the website that one of the reasons that you joined the PPA division of APESMA was because they had rungs on the board in negotiating fair wage agreements with some pharmacy groups, one of the things you would have been interested in as a committee member is what other agreements were being negotiated with pharmacy groups, do you agree?

PN1220

VICE PRESIDENT HATCHER: Mr Seck, whether there's enterprise agreements with pharmacies can just be established as a matter of independent fact, is it? What - - -?

PN1221

MR SECK: It can be, but I'm trying to establish it, your Honour, because I don't know what negotiations have taken place or not.

PN1222

VICE PRESIDENT HATCHER: Mr Yap, are you aware of any negotiations for enterprise agreements taking place apart from the two agreements you have identified?‑‑‑I'm just trying to think. I think there might be something about another hospital agreement that they're trying to get members for at the moment. I'm not sure whether it's just discussions or negotiations at this stage.

PN1223

MR SECK: As a committee member, Mr Yap, have you been involved in developing the strategy for pursuing more enterprise agreements?‑‑‑I'm not quite sure about the strategy to pursue more. We're given updates on what's - yes, if there's any discussions. But mostly their strategies that we discuss would be about the campaign to increase membership with Professional Pharmacists Australia.

PN1224

No further questions.

PN1225

VICE PRESIDENT HATCHER: Any re-examination, Ms Knowles?

***�� LEON YAP�� XXN MR SECK

RE-EXAMINATION BY MS KNOWLES�� [1.03 PM]

PN1226

MS KNOWLES: Mr Yap, you said in response to a question from Mr Seck that in the old - you know, when you became an owner, and that was in - - -?‑‑‑2001.

PN1227

Pardon me?‑‑‑Sorry. It was 2001, I believe.

PN1228

Yes, in 2001, thank you. You said that pharmacies were a lot more affordable in those days and the credit was easier to obtain. In what ways was it more affordable in those days in comparison to now - sorry, in what ways was it more affordable?‑‑‑I think at the time there was a shortage of pharmacists. I think there was a national shortage of pharmacists in 1998 (indistinct). So as far as I can recall, you could almost pick and choose where you could get a job; you could almost pick and choose, you know, if the pharmacy was available for sale. There weren't a lot of buyers in those days. So you could definitely find the pharmacy that you wanted a lot easier, and then in terms of more affordability, as I said, the main pharmacy wholesalers, the wholesalers themselves (indistinct) the pharmacy for dispensing, in those days would guarantee bank loans. So at the time, myself as - I think I was 20/21 years old, and my partner, we were able to obtain a bank loan to buy the pharmacies that we bought and the wholesaler guaranteed that loan to the bank, so it was far easier to get credit, and then the prices of pharmacies - - -

PN1229

Sorry, just on that, how does that compare to now?‑‑‑Well, definitely, I mean, as far as I know, wholesalers don't extend guarantees anymore. That was revoked a number of years ago. I think you need to be able to show a level of savings and have a certain amount of deposit. Admittedly I haven't looked into buying pharmacies for a little while, but definitely in terms of obtaining credit, it would be much more difficult, and then the availabilities of buying viable pharmacies I think is a lot harder now that there's a lot more - there's a lot more pharmacists, so if there's more pharmacists and not that many more pharmacies, obviously there's more competition for buying, and also there is a lot more large pharmacy groups, basically with lots of money and ability to massage ownership rules to purchase pharmacies. So the ability to actually get a pharmacy and get into ownership is much more difficult today.

PN1230

No further questions.

PN1231

VICE PRESIDENT HATCHER: Thank you for your evidence, Mr Yap. You're now excused and you're free to go.

<THE WITNESS WITHDREW�� [1.06 PM]

***�� LEON YAP�� RXN MS KNOWLES

PN1232

VICE PRESIDENT HATCHER: We will now adjourn and we'll resume at 2 pm.

LUNCHEON ADJOURNMENT�� [1.06 PM]

RESUMED�� [2.04 PM]

PN1233

VICE PRESIDENT HATCHER: Yes, Ms Madden is the next witness and she is on the telephone so we'll administer the oath or affirmation.

PN1234

THE ASSOCIATE: Hi, Ms Madden. Could you please state your full name and address?

PN1235

MS J MADDEN: Jennifer Ruth Madden, (address supplied).

PN1236

THE ASSOCIATE: Thank you, I'll now read out the affirmation.

<JENNIFER RUTH MADDEN, AFFIRMED�� [2.05 PM]

EXAMINATION-IN-CHIEF BY MS KNOWLES�� [2.05 PM]

PN1237

MS KNOWLES: Ms Madden, it's Ms Knowles here. Have you prepared a statement for these proceedings?‑‑‑I have.

PN1238

Is that a statement that is dated 14/12/2017 and it's nine pages long?‑‑‑That's correct.

PN1239

If I could take you to page 7 of your statement, the first dot point, is there a correction that you wish to make to that dot point?‑‑‑Yes.

PN1240

What is that correction?‑‑‑Instead of an 80 per cent pass rate, it's only a 75 per cent pass rate.

PN1241

With that correction, are the contents of your statement true and correct?‑‑‑Yes.

PN1242

I tender that.

PN1243

VICE PRESIDENT HATCHER: Yes, the statement of Jennifer Ruth Madden, dated 14 December 2017, will be marked exhibit 9.

EXHIBIT #9 WITNESS STATEMENT OF JENNIFER RUTH MADDEN DATED 14/12/2017

***�� JENNIFER RUTH MADDEN�� XN MS KNOWLES

PN1244

MS KNOWLES: Now, Vice President, I have a number of documents which are the Australian Association of Consultant Pharmacy documents which I wish to tender through Ms Madden. I understand there is no objection from my learned friend. They are simply documents which set out the accreditation process by the AACP. She has copies in front of her and we've just had some copies made now.

PN1245

VICE PRESIDENT HATCHER: All right.

PN1246

MS KNOWLES: So, Ms Madden, in front of you have you got a document that is the Australian Association of Consultant Pharmacy fact sheet number one - - -?‑‑‑Yes.

PN1247

- - - the facts about the Australian Association of Consultant Pharmacy?‑‑‑Yes.

PN1248

Do you recognise that document?‑‑‑I do.

PN1249

I tender that.

PN1250

VICE PRESIDENT HATCHER: Right, the document entitled, "Australian Association of Consultant Pharmacy fact sheet number one", will be marked exhibit 10.

PN1251

MS KNOWLES: Then, Ms Madden, if I take you to fact sheet number two, which is the Australian Association of Consultant Pharmacy fact sheet number two, the facts on remuneration for medication reviews, have you got that there?‑‑‑Yes.

PN1252

Do you recognise that document?‑‑‑I do.

PN1253

I tender that.

PN1254

VICE PRESIDENT HATCHER: Yes, all right.

PN1255

MS KNOWLES: Have you got a copy of that, Vice President?

PN1256

VICE PRESIDENT HATCHER: It's a bundle, is it? So this is, "Understanding the AACP stage two?"

***�� JENNIFER RUTH MADDEN�� XN MS KNOWLES

PN1257

MS KNOWLES: No, this is fact sheet number two, the facts on remuneration for medication reviews.

PN1258

VICE PRESIDENT HATCHER: All right, so AACP fact sheet number two will be marked exhibit 11.

PN1259

MS KNOWLES: Thank you. Then there should be fact sheet number three, which is the one-page document. Ms Madden, have you got there the Australian Association of Consultant Pharmacy fact sheet number three, the facts on the AACP accreditation assessment process?

PN1260

VICE PRESIDENT HATCHER: Ms Knowles, is it easier if I just mark this as a bundle of AACP documents?

PN1261

MS KNOWLES: Yes, yes.

PN1262

VICE PRESIDENT HATCHER: All right, I'll change those markings. So bundle of AACP documents will be marked exhibit 10.

EXHIBIT #10 BUNDLE OF AACP DOCUMENTS

PN1263

MS KNOWLES: Okay, and so within that bundle we have the fact sheet number one, fact sheet number two. Ms Madden, have you got fact sheet number three there? Do you recognise that document?‑‑‑Yes, I do have it.

PN1264

Then there should be fact sheet number five, which is the Australian Association of Consultant Pharmacy fact sheet number five, reaccreditation for MMRs?‑‑‑Yes.

PN1265

You recognise that?‑‑‑I do.

PN1266

Then you should have a document which is the Australian Association of Consultant Pharmacy, understanding the AACP stage two accreditation assessment process. Have you got that there?‑‑‑I have got that.

PN1267

Do you recognise that document?‑‑‑Yes, I do.

PN1268

Then lastly, have you got a document there which is the AACP costs associated with the AACP stage two accreditation assessment process?‑‑‑Yes, I do.

***�� JENNIFER RUTH MADDEN�� XN MS KNOWLES

PN1269

Do you recognise that document?‑‑‑I do.

PN1270

No further questions.

PN1271

VICE PRESIDENT HATCHER: All right, Ms Madden, Mr Seck, who is representing the Pharmacy Guild, will ask you some questions now. Please tell us if you can't hear anything he asks you?‑‑‑Okay.

CROSS-EXAMINATION BY MR SECK�� [2.10 PM]

PN1272

MR SECK: Ms Madden, it's Mr Seck here - can you hear me?‑‑‑Yes, I can.

PN1273

Now, you've just been - there have been a whole lot of documents which have been identified and marked as exhibit 10. Do you have those documents in front of you, Ms Madden?‑‑‑I do.

PN1274

Who is the Australian Association of Consultant Pharmacy?‑‑‑I beg your pardon?

PN1275

Who is the Australian Association of Consultant Pharmacy?‑‑‑Did you say who is?

PN1276

Yes, who are they?‑‑‑They're an organisation that was formed in conjunction with the Pharmaceutical Societies Australia and the Pharmacy Guild. The intention was to promote and seek recognition for the practice of consultant pharmacy. I became a consultant pharmacist. It took me about 18 months to prepare for that and the AACP was the only body at that time that was able to accredit accredited pharmacists. I think it still is.

PN1277

What is a consultant pharmacist?‑‑‑A consultant pharmacist has been given accreditation to perform domiciliary medication reviews, which they call MMRs, and residential medication management reviews, which are RMMRs. The HMRs are performed in a person's home or alternatively in a remote location if there is a particular reason that the home is not safe or acceptable and the RMMR is performed in a nursing home.

***�� JENNIFER RUTH MADDEN�� XXN MR SECK

PN1278

You've had - gone on?‑‑‑The RMMR process must be performed by an accredited pharmacist but the HMR process may be performed by a community pharmacist, so, for example, the pharmacist or the assistant pharmacist at the pharmacy that I contract with made because it's a remote location go and interview the person in their home and then they will send me the details and then I will write the report to the doctor. This is a very unsatisfactory of doing a medication review and I've only had to do it once and I've done over 800 medication reviews in the 16 years that I've been accredited.

PN1279

If you go to page 6 of your statement - - -?‑‑‑Page 6 of my statement?

PN1280

Yes?‑‑‑Just give me a moment. Yes.

PN1281

You see in the second bullet point there, you refer to RMMRs and HMRs?‑‑‑Yes.

PN1282

You say about 20 years ago, so given that you signed the statement in 2017 I gather you're referring to a period around 1997, that RMMRs and HMRs were developed, yes?‑‑‑I'm not entirely sure when they were started. I knew in 2002 when I became accredited that there were people that had been doing them for a few years. I believe that the RMMRs might have started in 1997 and HMRs shortly afterwards but I'm not entirely sure.

PN1283

Right?‑‑‑That's why I said, "about."

PN1284

And the RMMRs and HMRs, did they require accreditation 20 years ago, to the best of your knowledge?‑‑‑I had to become accredited in 2002 so you definitely had an accreditation process in 2002. My understanding was, because I went to a workshop before that, and I was very daunted by the process because there were case studies to do and the communication module to do - I'm not quite sure when accreditation - I thought it was at the very beginning, you required accreditation but I could be wrong.

PN1285

Right?‑‑‑But I thought it started from the very beginning.

***�� JENNIFER RUTH MADDEN�� XXN MR SECK

PN1286

Is it the case you work as a locum, Ms Madden, in the various jobs you've held as a locum would it be fair to say some jobs required you to exercise or to undertake RMMRs or HMRs and some jobs did not?‑‑‑Yes, when you do an RMMR, you actually contract with the nursing home and in the case of the nursing homes that I'm working with at the moment, the pharmacy contracts with the nursing home and then they find an accredited pharmacist. With the HMRs, you can do a direct HMR. The doctor might send you a referral directly which happens with me on occasions but most of my medication reviews are with the pharmacy. I have - there's about five or six, I can't count them just at the moment - maybe more pharmacies that I do medication reviews for. I am the pharmacist they choose. Other pharmacies have other pharmacists. There is a member of my family who is an accredited pharmacist. He performs medication reviews for his pharmacy. So I have no idea how many pharmacies would be involved in provision of medication reviews. I only know about my own situation.

PN1287

VICE PRESIDENT HATCHER: Ms Madden, do you know if community pharmacies ever engage pharmacists to do RMMRs?‑‑‑Yes, I'm engaged to do RMMRs for Yackandandah pharmacy - - -

PN1288

Right, okay?‑‑‑ - - - and for another pharmacy in Albury.

PN1289

I thought you said you did them under contract with nursing homes?‑‑‑Yes, the pharmacy has the contract with the nursing home.

PN1290

I see, all right, thank you?‑‑‑In a previous existence I had the contract with the nursing home, when I had a contract with one in north of me. I don't know whether you want me mentioning names of practices and pharmacies. I had the contract and I had the contract to also do the QUM and I was paid directly and that was a spin-off from the pharmacy that had the contract to do the medication reviews and the QUMs. It had the contract and then delegated to me and then they said, "Look, really it would be much easier if you just took the whole thing on." So about five years ago to eight years ago I was looking after a nursing home that had 55 beds. That was my baby. I did everything, in conjunction with the nurses and the doctors of course.

PN1291

All right, thank you.

PN1292

MR SECK: Ms Madden, it's Mr Seck here again - so I gather from your answer that in the case that you've just mentioned, the pharmacy was not conducting the RMMR because you decided to direct or you directly contracted with the residential nursing home, is that correct?‑‑‑Yes, on the recommendation of that pharmacy.

PN1293

Right, and so - go on?‑‑‑They were providing the Webster-paks for the nursing home.

***�� JENNIFER RUTH MADDEN�� XXN MR SECK

PN1294

Yes?‑‑‑They had a pharmacist and she went on maternity leave. She was doing their medication reviews. She lived locally. I had a connection with the pharmacy. They found out that I could do medication reviews and was accredited. They asked me if I would do it. I said yes. They continued to provide the QUM and then after about two or three years, they said to me, "Look, why don't you just take the whole thing on?" Then I negotiated directly with that nursing home and we have the contract - I have the contract with the nursing home but before that, the pharmacy had it and with the other pharmacies that I'm dealing with now, the other nursing homes that I'm dealing with now, I am employed by the pharmacy and paid by the pharmacy and they receive the payments from the CPA and then they pay me a proportion of that payment and I don't do anything about the QUM. They look after the QUM.

PN1295

Okay - go to page 2 of your statement. You say that you - this is about halfway down the page - it says, "In my work I contract a flat rate plus travel." Now, when you say in your other work you contract, am I right in understanding the other work is performing work as a pharmacist?‑‑‑As a pharmacist - - -

PN1296

Yes?‑‑‑ - - - but I have my own business - - -

PN1297

Yes?‑‑‑ - - - to provide medication reviews and locum services. But it's an unusual situation with this other pharmacy. I have a longstanding relationship with them going back even before I was doing medication reviews. So we've just maintained the process of me being a PAYG employee under those circumstances.

PN1298

Okay, now, you've said in your statement that you have always worked part-time during your 45 years as a pharmacist. Has that been a conscious, voluntary decision?‑‑‑Conscious, voluntary decision - I have seven children and I was more interested in parenting in the first part of my profession. My husband fortunately was a school teacher and I had a number of pharmacies where I would work during the school holidays and my husband would stay home and look after the children. Then when I went to Rockhampton, we moved to Rockhampton and my youngest child went into childcare I started working more of a job but never a full-time job because I always wanted to be home with the kids when they came home from school. I was very fortunate to be able to negotiate really good conditions and good times so I could start a little later in the morning and then knock off a bit earlier in the afternoon.

PN1299

When you say you were really fortunate to negotiate good conditions, that is you could work part-time and you received a rate which you thought fairly remunerated you for your services, is that right?‑‑‑Yes, yes - look, I don't remember - there was a time when the pharmacy rate was about $15 or $16 an hour. That's how long ago I go. But I usually receive above award payments.

PN1300

Okay, now, you say you've been working as a pharmacist since 1969, so you've probably seen a lot of changes during that period?‑‑‑I have seen a lot of changes.

PN1301

Now, you refer to on page 4 that initially you did a lot of extemporaneous preparation which I gather is compounding of medicines, that's right?‑‑‑Now, we're talking in the '70s and '80s.

***�� JENNIFER RUTH MADDEN�� XXN MR SECK

PN1302

Yes?‑‑‑You would make a thing like APC, a mixture of aspirin and phenacetin and caffeine. We would mix them up in bottles and then supply them to the patient. They had a very short life. They're probably terrible medicines, as it turns out, because the shelf life of aspirin in suspension but we'd give it a 30-day expiry date. You wouldn't get away with that now.

PN1303

And when you say you wouldn't get away with it, I gather you probably don't do much extemporaneous preparation any longer as part of your job as a pharmacist?‑‑‑The pharmacy I do most of my dispensing or there's one in particular that I nominated in the statement still has its lab, still has some extemporaneous products, but I haven't prepared - mostly creams and soap solutions were the ones, there is a dermatologist in Albury and she has a list of things that she prepares but the compounding pharmacists have really taken that over.

PN1304

During that time period you have no doubt had to deal with an expanding number of medications and having to since the 1970s learn about those new medications and their proper use to perform your job professionally as a pharmacist?‑‑‑Yes.

PN1305

That has been an ongoing feature of your job as a pharmacist since the very time you started as a pharmacist, do you agree?‑‑‑Yes, but the process has changed somewhat from when I very first started pharmacy and in the '80s. The process has changed so that the medicines - talking about medicines with patients now is different to what it was like before.

PN1306

When you say - go on?‑‑‑Patients were receptive of whatever the doctor ordered for them and pharmacists did not enter into any discussion about the medicine. In fact, sometimes we would call it, "the mixture." The patient had no idea what they were getting, whereas now the patient is expecting to know a lot more about their medicine. I remember we went through a process where we really had to be hyper-vigilant with patients because they were Googling for information and they were coming in the shop and asking for wrong medicines based on what they had read. So we started taking on an educational role, I think, in the use of medicine and that's when the QUM, the whole QUM concept came around, because pharmacists were seen as being the idea profession to be helping the patient to get good, useful information. So the expanding breadth of medications has - and the increased number of interactions, side effects - I think has increased the need for us to be more vigilant. We were always vigilant but it was a different sort of vigilance. It was kind of making sure the patient took the medicine and that we gave the right medicine to the right person.

***�� JENNIFER RUTH MADDEN�� XXN MR SECK

PN1307

That increase in vigilance which you talk about, Ms Madden, that has - I think you said it's different now to what it was back then. When you talk about, "back then", you're talking about over a period from the time you started to - - -?‑‑‑About - when computers came in - pharmacy changed when computers came in, from my experience, my personal experience, and that happened when I was living in Rockhampton, I think, in the '80s, towards the end of the '80s. that's when it happened in Rockhampton. Suddenly we were building up a profile of the patient and the medicines they were taking and we weren't just writing down in a book today that Mrs Jones had a prescription for digitalis. We had a very, very bad way of checking that Mrs Jones also got something else last month and it might have been something different and it might have been a different strength. But because the cross-checking wasn't possible because we didn't have computers, there would have been opportunity for lots of medication misadventures before the computers. But when computers came in we could see what the person had before. We could compare that with what was on the prescription. It made a huge difference to pharmacy, I think.

PN1308

You say on page 5 - that was around 1985, 1986?‑‑‑Look, you know, it was when I was in Rockhampton and I was in Rockhampton and Bundaberg. That was when I talked about the pirate program that was I think my last year in Bundaberg and that was '95, I think. I spent from - '85, I got the decade wrong - '85 to '89 in Rockhampton and then I came down to Wagga Wagga.

PN1309

Once you had computerisation and therefore access to the record of the patient's medicine stored on the computer, that allowed you to have more of an evaluative role about the medication which was being prescribed and how that might interact with other medicines which historically had been taken by the patient, correct?‑‑‑Yes, yes, that's true.

PN1310

That allowed you to have more discussions with the patient about the appropriate and proper use of that medication, do you agree?‑‑‑Yes, that's correct.

PN1311

So it would be - I think as you've pointed out, starting in the 1980s and moving onwards more discussions as technology improved and there was more information which allowed you to have those communications with the patients?‑‑‑That's right, yes - so that's what happened.

PN1312

That has been, would you agree, a constant evolution as new medications have arisen and new technologies have been used in the pharmacy?‑‑‑I would say, yes, during that time as the computers were being introduced but it's not all a rosy picture with computers.

PN1313

Part of it I think is - you referred to on page 6 also there is the information available had increased so for example there is a rapid - you say there was rapidly expanding drug compendiums available?‑‑‑I'm not quite sure where that is.

***�� JENNIFER RUTH MADDEN�� XXN MR SECK

PN1314

MS KNOWLES: On this page at the first dot point it says, "Sometime in the late 1990s", so I think the questions need to be more specific and if the witness is being taken to a particular place in the statement and being asked to respond to that she needs to be taken to it.

PN1315

MR SECK: I thought I took her to page 6, top bullet point?‑‑‑I found it there, I found it, yes.

PN1316

MS KNOWLES: But the question followed on from the previous one. You weren't being clear about the period which you were asking about.

PN1317

MR SECK: All right, so in the previous bullet point you had the 1980s and I'm moving now to the 1990s on page 6. Do you see that, Ms Madden?‑‑‑Yes.

PN1318

So you say, "At some time in the late 1990s there is a rapidly expanding drug compendium." So there is more information that becomes accessible to you, which allows you to - - -?‑‑‑When I said rapidly expanding I actually meant the compendium of drugs, not the compendium list of information.

PN1319

Pardon me, I wasn't intending to be misleading. So when you say, "compendium of drugs", that means there's more information about drugs for you to understand the nature and effect - - -?‑‑‑More drugs, therefore more reading, more learning about these medications, how they interact, pharmacology of them, that sort of thing, yes.

PN1320

But there have been - over time there is always going to be increasingly every year more drugs, would you agree with that?‑‑‑Yes.

PN1321

So the fact that there are more drugs is an inherent feature of what you have to deal with as a pharmacist?‑‑‑Yes.

PN1322

What the drug compendium allowed you to do was to have access to information in order to understand the nature of those medications and the proper use of those medications, yes?‑‑‑But at the same time, we were being required to print out information for patients and hand it to them and explain it to them.

***�� JENNIFER RUTH MADDEN�� XXN MR SECK

PN1323

Previously you didn't have computers to print out the material so you would have to explain it to them without the benefit of the printout, is that correct?‑‑‑Previously you didn't say anything to the patient about their medicine. Going right back, you didn't say anything to the patient about the medicine because that was what the doctor did. We didn't talk to them about medicines. We dispensed them.

PN1324

When you say - - -?‑‑‑We dispensed them but we didn't talk to them about it. But it became necessary to start speaking to them about the medicines. You say - I think on page 6 this started around the 1990s?‑‑‑Sometimes in the '90s - I don't know when. I think the CPDs became mandatory in the late '90s. I'm not clear on the time.

PN1325

You've been undertaking CPD or some form of continued education throughout your career?‑‑‑Yes.

PN1326

At least from the late 1990s, right?‑‑‑It was mandatory then - - -

PN1327

Right?‑‑‑I think we had to do it - it started off being about 20 or so over so many years.

PN1328

If I said to you that it's only became mandatory in the last few years, would that accord with your recollection or do you still think it was mandatory in the 1990s?‑‑‑No, I think it became mandatory around the turn of the century.

PN1329

Okay?‑‑‑That's when I thought. It was always mandatory - look, am I'm a pharmacologist. That's what my specialization was when I was doing pharmacy so I love drugs. I like to read about them so initially I read about them for enjoyment and it wasn't a burden for me for it to become mandatory. So I had colleagues who thought it was ridiculous, ridiculous that you have to do extra reading but I never felt that way so I'm kind of vague about when it became mandatory but I thought it was later than the 90s.

PN1330

That's all right. When you say you enjoyed it, you never felt that way about reading about drugs, did you see it as a necessary part of providing a high-quality professional service that you did your own reading about those drugs so you could provide proper advice as to the use of medication?‑‑‑Yes, yes, yes, but that was not part of my profession beforehand when provision of information was - it didn't happen. We didn't see that as part of our role.

***�� JENNIFER RUTH MADDEN�� XXN MR SECK

PN1331

When you say you didn't see that as part of your role, you saw it as part of your role, correct, because you thought you had to - - -?‑‑‑Yes, because I was very eager to embrace forward pharmacy - very eager. I got - there was a chain that started that was called Pharmacist Advice. When I worked at Ashmont - I think I've mentioned working at Ashmont - that was a forward pharmacy. That was fairly new then. That was I think the early 2000s and the idea of forward pharmacy was fairly new in the rural areas at least. That was terrific. I loved it. You know, they took away the step and we came down into the - almost into the shop front and the person came and sat with you at the computer while you did their prescription and you'd talk to them and you got a bit more of their history. You started asking them if they were allergic to anything. We never asked people if they were allergic to anything before because we didn't need to know.

PN1332

When you say you didn't need to know before, one of the things you would need to do - let me go back to that. In the nature of the services that you provided there are different schedules of medicine as you understand it, that's correct?‑‑‑Yes, yes, correct.

PN1333

The schedule of medicines I think you say didn't exist when you started and that was something that was introduced whilst you were working as a pharmacist?‑‑‑Look, well, there were things in S2 and things in S1. I think arsenic was S1 and you needed to get the pharmacist to sign for arsenic. When I was writing this I was trying to get hold of an old poisons schedule but I couldn't find one anywhere so I've done this basically from memory. I don't believe there was anything that was S3. S3 came in - the first thing I seem to remember being an S3 medicine was Ventolin. I'm not quite sure when that was scheduled S3 but I think it was late '90s. I don't know. That seems to me to be the first thing. You might be able to tell me. I don't know.

PN1334

But it would be fair to say that you've been dealing with scheduling of medicines since at least the 1980s?‑‑‑Yes.

PN1335

There would be movement of drugs between schedules from time to time?‑‑‑Yes.

***�� JENNIFER RUTH MADDEN�� XXN MR SECK

PN1336

So when schedules moved up or down into different schedules you would have to potentially learn about new medications and the effects as part of your role?‑‑‑Well, the effect of the medication doesn't change because it's been rescheduled but the - if it becomes a schedule 3 medication you certainly have to communicate to a person when they're coming in to buy the medicine whereas if you were dispensing that on the first dispensing you would provide them with a CMI and you would have a conversation. So it's a different process depending on the schedule. We counsel on S2 medicines as well if a person comes in and says, "I've got a headache." The dispensary assistant gets the pharmacist to come and talk about that because they are not rained to respond to a symptom-based request. They can respond to a product-based request, for example, "Can I have some Panadol?" But if they come in and say, "I've got a headache", then the pharmacist is called to make some sort of judgement about whether that person is perhaps having something serious happening and they need to go to hospital and not buy some Panadol. This is what happened when S2s, particularly the S3s came. We had to start making judgements about is it appropriate to give this person some Ventolin? If a doctor wrote a prescription for Ventolin you would dispense it. You wouldn't say, "Is this a good idea to give them Ventolin?" But if a person came in and made a request, they've refused people requests for Ventolin on the basis of what they've proceeded to tell me because it was not appropriate medication in their case. This all happened when the S2s and S3s started happening and that, I'm sure, was late '90s, early 2000s. Now we've got so many S3s that you might be called to do an S3 medication six or seven times in a morning.

PN1337

As you say there has been movement down the schedule which has been occurring since schedules existed?‑‑‑Most things go down.

PN1338

Yes?‑‑‑Thank god codeine went up.

PN1339

You also say in your statement that in - this is on page 4 - you were focused on amongst other things skills to be a good business person?‑‑‑That's right.

PN1340

What skills did you acquire as a businessperson after you - during your intern year and subsequently in those early years?‑‑‑Well, I think you also read there that my preceptor - he wasn't my preceptor, he was my boss - he valued his reputation so much that he didn't let me develop my skills. This still happens a lot in pharmacies for interns. They don't have the ability to develop their skills but I didn't have much of an opportunity to develop my skills, so much so that I didn't feel confident to practice pharmacy, even at the end of my preceptor training year.

PN1341

Now - - -?‑‑‑I made the - - -

PN1342

Go on?‑‑‑I made the choice to go to research, to go back to the university. Then by way of the university I started getting some part-time jobs to help me pay my way through and that's where I started learning to be a pharmacist and I realise I never wanted to be an owner of a pharmacy. I realise that fairly early in my profession. So learning those skills wasn't very important. I concentrated on the medicines. I started trying to become very proficient at knowing about medicines which is what led me to the medication review side.

PN1343

Why did you decide not to become a pharmacy proprietor?‑‑‑I had no money. I had a small family and I had no interest.

PN1344

Okay. No further questions.

***�� JENNIFER RUTH MADDEN�� XXN MR SECK

PN1345

VICE PRESIDENT HATCHER: Any re-examination, Ms Knowles?

RE-EXAMINATION BY MS KNOWLES�� [2.43 PM]

PN1346

MS KNOWLES: Ms Madden, in response to a question you were asked about compounding, you said that the compounding pharmacists have really taken that over. Why is that?‑‑‑Why is that?

PN1347

Ms Madden, if you don't know I won't ask you to speculate?‑‑‑Well, no, I would be speculating because I've never been a proprietor to estimate whether there is any value in doing it now that there's people that are specializing in it.

PN1348

All right, and you were asked some questions about when the CPD became mandatory and you were a bit unsure about that. As an accredited pharmacist, do you have to undertake mandatory CPD?‑‑‑Yes and I have to do 20 hours more than a community pharmacist.

PN1349

How long have you been having to do that?‑‑‑It wasn't at the very beginning. I was looking back through my certificates and I believe in the first - for my first two or three re-accreditations I only had to do 120 over three years. But I think since maybe 2008 maybe it's been - because I've re-accredited every three years and 2008 was one of my re-accreditation years. I think it was 60 then. I don't mind how many hours I have to do. I always get lots and lots of reading done. It's part of the job of doing a medication review. You have to do a lot of reading.

PN1350

Thank you, Ms Madden - no further questions.

PN1351

VICE PRESIDENT HATCHER: Thanks very much, Ms Madden. You're excused, which means you're free to go and you can simply hand up the phone?‑‑‑Okay, thank you very much.

<THE WITNESS WITHDREW�� [2.45 PM]

PN1352

VICE PRESIDENT HATCHER: Who is the next witness?

PN1353

MS KNOWLES: Vice President, we have arranged for Professor Clarke. We had given him a tentative time of around 3 o'clock and he has had to go to the Commission in Melbourne for the video link so I'm wondering whether we might be able to have him first if I could make a call to see if he's available, rather than have him wait for Ms McCallum?

PN1354

VICE PRESIDENT HATCHER: All right, well, we'll take a short adjournment and you can tell my associate when you're ready.

***�� JENNIFER RUTH MADDEN�� RXN MS KNOWLES

SHORT ADJOURNMENT�� [2.46 PM]

RESUMED�� [3.10 PM]

PN1355

VICE PRESIDENT HATCHER: Mr Irving.

PN1356

MR IRVING: Yes, we have Professor Clarke.

PN1357

VICE PRESIDENT HATCHER: Right.

PN1358

MR IRVING: Perhaps if he could be - - -

PN1359

VICE PRESIDENT HATCHER: Yes.

PN1360

THE ASSOCIATE: Professor Clarke, could you please state your full name and address?

PN1361

PROF CLARKE: Phillip Miles Clarke, (address supplied).

PN1362

THE ASSOCIATE: I'm now going to read out the affirmation.

<PHILLIP MILES CLARKE, AFFIRMED�� [3.10 PM]

EXAMINATION-IN-CHIEF BY MR IRVING�� [3.10 PM]

PN1363

MR IRVING: Is your name Professor Phillip Clarke?‑‑‑Yes.

PN1364

Could you state your occupation?‑‑‑I'm a health economist.

PN1365

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

PN1366

Do you have that in front of you?‑‑‑Yes, I do.

PN1367

Is that titled, "Report Prepared for Professional Pharmacists Australia Providing Data and Information on Aspects of Pharmacy Ownership, Pharmacy Revenue and Business Sale Prices"?‑‑‑Yes.

***�� PHILLIP MILES CLARKE�� XN MR IRVING

PN1368

Are the contents of that report true and correct?‑‑‑As far as I'm aware, yes.

PN1369

I tender that statement.

PN1370

VICE PRESIDENT HATCHER: Mr Irving, are you including the CV and the other documents as part of the tender?

PN1371

MR IRVING: I was about to - yes, if I could, your Honour. They are annexures D to the material that was filed in 2016.

PN1372

VICE PRESIDENT HATCHER: If we just call it report of Professor Phillip Clarke and associated documents and just treat them as one bundle, is that appropriate?

PN1373

MR IRVING: Yes.

PN1374

VICE PRESIDENT HATCHER: So the report of Professor Phillip Clarke and associated documents will be marked exhibit 11.

EXHIBIT #11 REPORT OF PROFESSOR PHILLIP CLARKE AND ASSOCIATED DOCUMENTS

PN1375

MR IRVING: Thank you. Professor Clarke are you the chair of health economics at the centre for the Melbourne School of Population and Global Health?‑‑‑Yes.

PN1376

Do you hold a Bachelor of Economics and Master of Economics and a PHD?‑‑‑Yes.

PN1377

Are you a fellow of the Academy of Social Sciences?‑‑‑Yes.

PN1378

Are you the author of some 80-odd journal articles, including an article on pharmaceuticals, pharmacists and profits, a health policy perspective?‑‑‑Yes, I'm now - I've got 110 article, but yes.

PN1379

You currently are working on four NHMRC grants and an ARC grant?‑‑‑Yes.

PN1380

Okay. They're the questions in chief, your Honour.

***�� PHILLIP MILES CLARKE�� XN MR IRVING

PN1381

VICE PRESIDENT HATCHER: Thank you. Mr Seck.

CROSS-EXAMINATION BY MR SECK�� [3.13 PM]

PN1382

MR SECK: Thank you, your Honour. Professor Clarke, I am the counsel for the Pharmacy Guild of Australia. I'm just going to ask you a few questions about your report and the area of the economics of pharmacies?‑‑‑Yes.

PN1383

You're aware of the national medicines policy of the Commonwealth government?‑‑‑Yes.

PN1384

The objectives of the national medicines policy, amongst other things, is affordable, timely and safe access to use of medicines?‑‑‑Yes.

PN1385

One of the instruments through which the Commonwealth government implements its national medicines policy is through the pharmaceutical benefits scheme and the regulation of pharmacies. Do you agree?‑‑‑Yes.

PN1386

You have in your report reference to a number of the mechanisms through which both the Commonwealth and state and territory governments regulate pharmacies and I just want to take you through some of those matters. One of the mechanisms by which the Commonwealth government seeks to regulate pharmacies is through the pharmaceutical benefits scheme - - -?‑‑‑Yes.

PN1387

- - - as well as through community pharmacy agreements?‑‑‑Yes, yes, and I suppose I would say with pharmaceutical benefits scheme, it regulates those that are signed up to be - to spend under the pharmaceutical benefits scheme.

PN1388

By that what you are saying, Professor Clarke, is that not every pharmacist which is registered is necessarily signed up to the PBS?‑‑‑Yes, I believe so.

PN1389

For example, there might be some pharmacies which are merely retail pharmacies which do not participate in the PBS. Is that correct?‑‑‑I believe so, yes.

PN1390

Would you therefore say that in one sense pharmacies act as the agents for the implementation of the Commonwealth government's national medicines policy?‑‑‑I suppose they are one of the players that would form part of the policy, yes.

***�� PHILLIP MILES CLARKE�� XXN MR SECK

PN1391

I'm not suggesting that they're the only player but they're an important player in the implementation of the policy, you would agree?‑‑‑Yes.

PN1392

Which means - I want to go through some of the mechanisms for regulating the pharmacy industry in particular through the Commonwealth government. Now, at a high level tell me if you agree that the PBS is a system by which the government remunerates pharmacies for scheduled medicines. That's right?‑‑‑I mean, I think the primary purpose of the PBS is to make medicines accessible to Australians at prices they can afford but as part of that process there is a process of remuneration that is built in to the benefits that the Commonwealth is paying.

PN1393

The remuneration is based on dispensing scripts, that's right?‑‑‑Yes, and there are I suppose or there have traditionally been other channels of remuneration but yes, primarily through dispensing of scripts.

PN1394

That - I think you talked about proving accessible medicines at a cost-effective price or words to that effect. As part of that, there are regulations which restrict the co-payments which can be charged by pharmacists for dispending those scripts?‑‑‑My understanding - and this just based on the recent report of the pharmacy remuneration - is that yes, that applies to co-payments, definitely apply to concessional patients.

PN1395

Yes?‑‑‑When it's below co-payment for the general patients, there isn't a regulation of prices but yes, for scripts dispensed under the PBS, yes, there are set co-payments. I mean, strictly I would use the term in economic terms, they're actually strictly a fixed front-end deductible because co-payments vary with the price of the drug. These are fixed at a fixed fee.

PN1396

The remuneration under the PBS, that is - those fees are established by the pharmaceutical benefits remuneration tribunal, is that so?‑‑‑That is my understanding but I wouldn't say that's an area of my expertise, of how they're set.

PN1397

In your study of the Australia community pharmacy industry, would you agree, Dr Clarke, that on average about 65 per cent to 70 per cent of the income earned by the Australian community pharmacy industry is from remuneration under the PBS scheme?‑‑‑I mean, a significant proportion, yes - that sounds about right. I'd have to check figures to be able to confirm that exact amount but yes, that sounds right.

PN1398

One of the other instruments through which the Commonwealth government regulates pharmacies is through the community pharmacy agreements and the pharmacy practice incentives which are provided for under those agreements. Is that your understanding?‑‑‑Yes.

***�� PHILLIP MILES CLARKE�� XXN MR SECK

PN1399

The pharmacy practice incentives are particular programs which are funded or subsidised by the government or pharmacies to provide to patients in the community, that's right?‑‑‑Yes, that's my understanding, yes.

PN1400

There are particular performance benchmarks that have to be met in order to receive those incentives?‑‑‑I understand there are some, yes, under the guild government agreement.

PN1401

Now, pharmacies are also regulated, according to your report, by state and territory governments, that's right?‑‑‑Yes, absolutely, yes, particularly around the areas of ownership, yes.

PN1402

Areas of ownership and areas of professional standards?‑‑‑Yes.

PN1403

It's also regulated in terms of ethical obligations as well as quality standards?‑‑‑That's my understanding but again, that's probably - strays from my sort of strict area of expertise but yes, that's my understanding.

PN1404

There are also restrictions on the ownership or proprietary interests that pharmacists can have in pharmacy businesses?‑‑‑Yes, that is my understanding, yes, at a state level, yes.

PN1405

By and large - it's by no means an exhaustive statement - but the people or the individuals who can own and conduct the operation of a pharmacy are generally restricted to registered pharmacists, companies whose directors or shareholders are registered pharmacists or friendly societies?‑‑‑That's my understanding, yes, since the late 1930s that has been the case.

PN1406

To the best of your understanding, Dr Clarke, one of the purposes of that is to ensure that pharmacies are supervised and managed by people who have qualifications and experience as pharmacists, that's right?‑‑‑I think that has been put forward but I wouldn't say that that's from an economic perspective - you know, there is a good argument for that. But that has certainly been put forward.

PN1407

Is that your understanding of the rationale for why the ownership restrictions exist?‑‑‑My understanding of the reason the ownership rules were initially proposed was to prevent a chain pharmacy, Boots, from entering into Australia in the late 1930s. That's my understanding of - reading the historical documents at the time, that there was a campaign by community pharmacists to prevent Boots entering Australia but, yes, that's my reading of the historical documents.

***�� PHILLIP MILES CLARKE�� XXN MR SECK

PN1408

Pharmacists, because they are subject to state and territory as well as Commonwealth regulation can be the subject of disciplinary action if they don't meet particular professional standards, that's right?‑‑‑Yes, I believe so.

PN1409

If they don't meet those professional standards they can be subject to disciplinary action, including losing their registration to practice as a pharmacist?‑‑‑Yes, yes.

PN1410

Is your understanding as well that pharmacists - once they're deregistered obviously they can no longer own the pharmacies. That's a logical corollary - - -?‑‑‑I don't know that, actually. I can't comment. That's probably beyond my level of knowledge of the specifics around the regulation.

PN1411

Another aspect of the regulation, Dr Clarke, is through the therapeutic goods act and the poison standards? You're aware of that?‑‑‑Yes, yes.

PN1412

In particular, the scheduling and unscheduling of particular medicines?‑‑‑Yes.

PN1413

Now, another aspect of the regulation of pharmacists I wanted to ask you about is price disclosure. Are you aware of the process of price disclosure?‑‑‑Yes, that's an area I've done quite a lot of research on.

PN1414

Right. Just explain to the Commission what is price disclosure?‑‑‑So effectively it was a policy introduced in 2006 by a former health minister, then Tony Abbott. Explicitly, Australia had a problem with high generic drug prices so what tended to happen was when prices - when drugs went off patent and became generic there was very limited competition and any sort of mechanism by which the government benefits would decline. What Tony Abbott introduced in 2006 was a process by which the companies had to disclose the prices, the actually traded prices that they were selling to pharmacists where there were very in some cases large discounts and that would be used to set future benefits. So let's say drug X, the benefit, let's say, is $30. But you observe the traded prices, the actual discount or the wholesale price is $30, the traded prices are actually $10 on average. That would be used as the basis for setting a future benefit down to $10. So that has resulted - price disclosure has resulted in many declines in prices of some of - quite a large number of generic drugs.

***�� PHILLIP MILES CLARKE�� XXN MR SECK

PN1415

Is one of the business impacts of price disclosure, Dr Clarke, that it reduces the difference in the price paid by pharmacists and what is received by pharmacists under the PBS, therefore reducing profitability?‑‑‑So what happens - it's a very interesting speech that I would urge you to read by Tony Abbott when he introduced the legislation. It was a press conference and what he said was he recognised that, he gave a compensation but he said it was one-off and that pharmacies had to change their practices under the new regime where generic drug prices were going to decline significantly.

PN1416

Has your research extended to looking at the impact of price disclosure upon the profitability of pharmacies?‑‑‑I've certainly calculated the - I have made in the past some calculations of the sort of total amount of discounts that pharmacists got. I don't have the exact figures with me but they certainly were in the orders of many tens of thousands per pharmacy. Probably discounts peaked in about 2012, 2013, and they're declined, although what has happened, of course, is there have been changes and subsequent reforms to the legislation to speed up the acceleration of declines in generic prices. But there are still discounts. It's still a retrospective price-setting system so pharmacists will always get a greater - I mean, I suppose I would use the term - perhaps a hidden benefit, a benefit that is not transparently revealed through anything except looking at it retrospectively through price disclosure.

PN1417

I think when you talk about the acceleration of the periods you're talking about simplified price disclosure, are you not?‑‑‑I believe so, yes, so with - what the Gillard government introduced in 2013, that had quite a significant effect on the rate of disclosure by reducing the time period over which prices were collected and the price changes were made.

PN1418

Because it's retrospective, I think you were pointing out, Dr Clarke, that there is a lag period, in effect, where there might be the benefit of price disclosure for the pharmacies but that lag period has reduced from a longer period - I think it's about 18 months - to a shorter period of about six months. Would that accord with your understanding?‑‑‑Yes, that is my understanding, and there have been some other adjustments, particularly made by the former health minister which would also additionally accelerate the disclosure about the counting, I think, of brands as opposed to generics in terms of the formula that had been effective in reducing the prices and perhaps just to give people an indication of the difference in prices that Australian tax payers were paying relative to other countries - in some cases we're talking about 10 and 20-fold difference in prices between us and say a comparable country like the UK.

PN1419

Because of simplified price disclosure, you would agree that on one hand it's provided better value for the Commonwealth government but also it's reduced the profitability that pharmacies can obtain from that lag period?‑‑‑I mean, I think the discounts have declined. It's hard to assess the impact on profitability but yes, the benefits that they were getting, beyond the standard sort of remuneration, has declined, or that source of benefits.

***�� PHILLIP MILES CLARKE�� XXN MR SECK

PN1420

Now, would you agree that by pharmacies being - community pharmacies being highly regulated and one of the instruments through which the national medicines policy is implemented by the Commonwealth government, there are limitations placed upon pharmacy owners being able to earn a certain, unlimited profit?‑‑‑I'm not aware of that but I don't know what regulations you are referring to there.

PN1421

All right, so let me just take you through some more specific stuff and we'll come back to that point. You also refer to in your report, Dr Clarke, to location rules?‑‑‑Yes.

PN1422

Now, as I understand it the location rules are supervised and regulated by the Australian Community Pharmacy Authority, that's right?‑‑‑That's my understanding, yes.

PN1423

You point out that - I think you say that the pharmacy's ownership - sorry, I should go back: "Location rules restrictions have prevented new entrants into the sector." You say that at the bottom of page 1 of your report?‑‑‑Yes, in terms of that clearly you can't set up a pharmacy within a given distance of an existing pharmacy. Yes, it does restrict new entrants in that manner.

PN1424

But it doesn't restrict I suppose new entrants into areas where there may not be a pharmacy in the location or where there - - -?‑‑‑My understanding - that was the case. Having said that, I am mindful of a talk Professor King, the productivity commission, gave publicly and he said that traditionally the setting of a pharmacy was purely based on distance but I think there is no - there has been some additional regulations added. But I'm not full across those but it's not just purely based on distance, your right to privacy and prescribe on the PBS.

PN1425

Right, so it doesn't absolutely restrict new entrants, it just regulates new entrants in terms of where they can set up a new business?‑‑‑Yes, yes, but there are additional restrictions as well, beyond just distance as well.

PN1426

Those restrictions might include the location of the pharmacy?‑‑‑My understanding is there was a case in North Queensland of a pharmacy that set up 10 km out of town and that under the previous rules was allowed. These days it would be more difficult but I don't know - I mean, I'm relating a talk given by Professor King rather than knowing the exact details myself.

***�� PHILLIP MILES CLARKE�� XXN MR SECK

PN1427

All right, so it would be fair to say that whilst you're familiar with the general rules, not familiar with the detail of how those location rules may operate in any particular situation?‑‑‑Yes, I'm familiar with the general principles rather than every clause. The document is what, 55 pages or thereabouts so no, I'm not across every one of those rules.

PN1428

VICE PRESIDENT HATCHER: Professor Clarke, are you able to say whether the restrictions you describe on your entrance would have effect on the labour market for pharmacists?‑‑‑Yes, I mean, I believe they may well have. In terms of obviously - I think there are, I suppose, a few issues with the location rules. Effectively, what it's done is kept the number of pharmacies in Australia basically constant or actually below what it was in the late 1960s and so effectively it's frozen both in the location and the number of pharmacies effectively across Australia. Clearly, the number of pharmacists operating within those pharmacies has risen so I think clearly the pharmacy-to-population ratio is clearly rising in Australia. But the pharmacist-to-population ratio if anything I think is falling but it's certainly - the numbers are rising. Interestingly if we compare ourselves with other OECD countries, which I did in the submission, we have I suppose less on average of pharmacies in Australia compared to per 100,000 of population but more pharmacists as it were. So I suppose that it does change the labour-market bargaining power.

PN1429

What might happen, I think, perhaps on a location-specific basis is potentially there is nothing to prevent a pharmacist owning more than one pharmacy and potentially owning several pharmacies, both within the same town or within the same suburb and again, I think that is creating sort of a local monopoly. That may again change the bargaining power that if you lived in an isolated town and two pharmacies were owned by the same person, what's your ability to basically negotiate and say that, "I will look to go to the other pharmacy to seek better wages."

PN1430

Just hold on a second. Mr Seck, I hate to do this - can I ask you to stand up and sit down, please?

PN1431

MR SECK: Yes, yes.

PN1432

VICE PRESIDENT HATCHER: We have - thank you. I'll just try to follow up on that - if controls on new entrants - would that have the likely result of restricting the total number of jobs for employed pharmacists that might otherwise exist if there were no controls on entrants to the industry?‑‑‑I suspect if you removed the location rules there would be new entrants. I suspect it would also give the right of an employed pharmacists in a pharmacy to basically, like any small business, open up a store as it were down the street from the person where they had worked, which clearly they can't do here and I think that is obviously quite significant - a difference between this and other labour markets operating in small businesses in Australia.

***�� PHILLIP MILES CLARKE�� XXN MR SECK

PN1433

Would the result of that be to suppress the price - the labour price of pharmacists in the market, that is employed pharmacists?‑‑‑What do you mean, in terms of what - - -

PN1434

Well, if you're suppressing employment opportunities for employed pharmacists by suppressing the number of businesses, does that in turn suppress the price of their labour?‑‑‑Well, I mean, one would think - and I must stress I'm a health economist, not a labour economist but I have studied labour economics in my economic training. One would always think when you've got a monopoly or some degree of monopoly by the employer, the bargaining powers change and one would suspect that would potentially put a downward pressure on wages.

PN1435

Thank you.

PN1436

MR SECK: Just to explore that, Dr Clarke, you say where pharmacists have monopoly - of course you're aware that there is a restriction on the number of pharmacies that a pharmacist can own under state and territory legislation?‑‑‑Yes, yes, I am aware but it's quite - my understanding is it varies by state but it is now in some states they can own quite a few. I believe five but I'm not - in some states and also I think you can get for example, family structures where families own - I mean, a single family, several players within the family own different pharmacies. So I think the ownership - there is not I don't believe good public data on this, the ownership concentration in terms of the number of owners and how many pharmacies they own. I believe there is a degree of concentration but I haven't seen data to exactly define what that is and how that is changing over time.

PN1437

The fact that there are restrictions on a number of pharmacies that can be owned by a pharmacy would actually avoid concentration rather than promote concentration, would you agree?‑‑‑Not if it's in a labour market such as in a rural town where you own both pharmacies or in a suburb where you potentially - I mean, clearly potentially obviously in cities people have access to other employers but clearly owning pharmacies that are as it were located near each other obviously is going to have - to a degree it is going to change the as it were I suppose - or give pharmacies a local degree of monopoly power.

PN1438

Are you aware of any examples where that has occurred?‑‑‑No, I don't - I mean, I'm using as it were economic principles here, not data. I'm not aware of data but I would like to analyse it if it exists.

***�� PHILLIP MILES CLARKE�� XXN MR SECK

PN1439

One of the purposes, you understand, of location rules is to ensure that there is an even spread of pharmacies to population centres. Do you accept that?‑‑‑I believe that's been put up as a rationale, yes. I don't know if I think it's a sensible rationale but I believe that's what is being asserted as a rationale.

PN1440

IN light of these regulations that apply within the community pharmacy industry to who can own a pharmacy, who can dispense a pharmacy, who may practice as a pharmacist and supply, price and location, would you agree that all these regulatory restrictions means that pharmacies don't operate in accordance with a standard, corporatized, profit-driven model but these are - this is the balance which has been struck so that pharmacists can perform in part a public health function?‑‑‑It's an interesting question. I mean, I think obviously they are small businesses. Ultimately they are - they can go bankrupt and they can make profits and they retain those profits, is my understanding.

PN1441

When you say in your report that there are some pharmacies which are highly profitable and can earn millions of dollars, that's not to say all pharmacies fall within that category?‑‑‑Absolutely not.

PN1442

There would be pharmacies who would fall at the opposite end - for example, a pharmacy in a small country town?‑‑‑Potentially - I mean, it depends on the country town, obviously, and the size. But yes, clearly there is no question. I mean, the data here is extremely limited, I must stress, so the good, public data you've got only comes really from the national audit office report looking at the remuneration per pharmacy and providing the first time public data. I don't believe that has ever been released publicly again which I think makes it very hard to track profitability over time. But of course what you're only seeing is one side, which is the benefits paid by the Commonwealth. What you really need obviously is the costs and I think it is noticeable in the recent report to the government that there were recommendations that there be much more sort of transparency around the costs and developing an accounting standard and that was recommended by at least two of the people on the tribunal looking into that.

***�� PHILLIP MILES CLARKE�� XXN MR SECK

PN1443

I think what you are acknowledging, Dr Clarke, is that the data which allows you to draw conclusions about the profitability of pharmacies is imperfect and is ultimately based on averages rather than looking at the specific profitability of individual pharmacies?‑‑‑Yes, and I have sought on a couple of occasions to improve that data. I have sought that data from the Commonwealth Department of Health and that hasn't been provided. I have suggested that they - interestingly there are quite different standards applied by the Commonwealth when it comes to the reporting of similar benefits. So for example, when it comes to pharmaceutical companies, when you look at the PBS annual - I think it's annual expenditure reports, they report with identified pharmaceutical companies the top-twenty earners out of the - as it were out of the PBS. I did propose to them that they should report the top-20 pharmacy owners in Australia. They haven't done so. I've also made submissions to one of the Senate inquiries suggesting that it would be valuable data to repeat the national audit office data at a pharmacy - at an identified pharmacy level.

PN1444

I want to pick up a line of questioning which the Vice President asked you about earlier, which is the impact of these regulatory restrictions upon the labour market. I know it's not your area of expertise so please tell me if you can't answer the questions, Dr Clarke. The impact on the labour market of these regulatory restrictions would ultimately be largely determined by both demand factors and supply factors. That's basic economics, obviously?‑‑‑Yes, I would believe so, yes.

PN1445

How the regulatory restrictions may impact would also have to look at the availability and numbers of pharmacists in the labour market? Have you looked into this issue beforehand?‑‑‑What do you mean, in terms of the - - -

PN1446

Sorry - in terms of how many pharmacists are out there in the labour market looking for jobs?‑‑‑No, I haven't. I haven't specifically looked at it. As you can see, which I put in the report, is that you can get the total number of pharmacists and calculate pharmacy-to-population ratios. I don't know the degree of unemployment amongst registered pharmacists, no.

PN1447

No further questions.

PN1448

VICE PRESIDENT HATCHER: Professor Clarke, is there any equivalent to the location rules or the ownership rules in respect of medical practitioners?‑‑‑Not that I'm aware, no.

PN1449

Thank you. Any re-examination, Mr Irving?

PN1450

MR IRVING: No, your Honour. But I did want to mention this - as Professor Clarke has set out in this statement, he has come along here today not to provide a report pursuant to any payment, but as a member of the public who has come to share what he knows about the matter with the Commission.

PN1451

VICE PRESIDENT HATCHER: Yes, all right.

PN1452

MR IRVING: I thank him for that.

PN1453

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

***�� PHILLIP MILES CLARKE�� XXN MR SECK

<THE WITNESS WITHDREW�� [3.43 PM]

PN1454

MR IRVING: Ms Knowles will take the final witness if we have time?

PN1455

VICE PRESIDENT HATCHER: How long will that witness take?

PN1456

MS KNOWLES: If my learned friend would like to - - -

PN1457

VICE PRESIDENT HATCHER: How long will that take, would you say, Mr Seck?

PN1458

MR SECK: Half an hour.

PN1459

VICE PRESIDENT HATCHER: We need to - we need to finish by about 10 past, so - - -

PN1460

MR SECK: I'll endeavour to do that by 10 past.

PN1461

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

PN1462

MS C McCALLUM: Carmel Mary McCallum, (address supplied).

<CARMEL MARY MCCALLUM, AFFIRMED�� [3.44 PM]

EXAMINATION-IN-CHIEF BY MS KNOWLES�� [3.44 PM]

PN1463

VICE PRESIDENT HATCHER: Ms Knowles.

PN1464

MS KNOWLES: Ms McCallum, have you prepared a statement for this proceeding?‑‑‑I have.

PN1465

Do you have that in front of you? I think it would be tab - - -?‑‑‑I found it.

PN1466

Is that a statement dated 18 December 2017, which is eight pages long and 29 paragraphs long?‑‑‑It is.

***�� CARMEL MARY MCCALLUM�� XN MS KNOWLES

PN1467

I'm just going to have a document handed to you. You see that document there which is amendments to statement of Carmel Mary McCallum?‑‑‑Yes.

PN1468

With those amendments to your statement, are its contents true and correct?‑‑‑Yes, they are.

PN1469

I tender that.

PN1470

VICE PRESIDENT HATCHER: All right, perhaps we'll just mark the corrections on the statement. Ms Knowles, can you just take us to where those corrections are?

PN1471

MS KNOWLES: Yes, so you go to paragraph 21, page 5, at the beginning of the second sentence - - -

PN1472

VICE PRESIDENT HATCHER: The one beginning, "Workloads?"

PN1473

MS KNOWLES: Yes.

PN1474

VICE PRESIDENT HATCHER: So we add the words, "from about 2,000", before that?

PN1475

MS KNOWLES: Yes.

PN1476

VICE PRESIDENT HATCHER: Yes, all right.

PN1477

MS KNOWLES: Then if you go to page 6, the second sentence from the top - - -

PN1478

VICE PRESIDENT HATCHER: Beginning with - - -

PN1479

MS KNOWLES: - - - just in front of the words, "1990s", so it reads, "since the late 1990s."

PN1480

VICE PRESIDENT HATCHER: That's in the third line?

PN1481

MS KNOWLES: Yes.

***�� CARMEL MARY MCCALLUM�� XN MS KNOWLES

PN1482

VICE PRESIDENT HATCHER: Yes.

PN1483

MS KNOWLES: Then - I've done it by sentence, Vice President. You're probably right that going by line is the easiest. So I've counted down to the 10th sentence, which is three quarters of the way down - it's probably easiest to go from the bottom.

PN1484

VICE PRESIDENT HATCHER: Starting with what?

PN1485

MS KNOWLES: "There has also been an exponential increase" - - -

PN1486

VICE PRESIDENT HATCHER: Yes.

PN1487

MS KNOWLES: Then if the words - "in the last six or seven years."

PN1488

VICE PRESIDENT HATCHER: Yes.

PN1489

MS KNOWLES: Then in the last sentence on that page, before, "we also have", if we add the words, "in the last 10 years."

PN1490

VICE PRESIDENT HATCHER: Right, so the statement of Carmel Mary McCallum dated 18 December 2017 subject to those corrections will be marked exhibit 12.

EXHIBIT #12 WITNESS STATEMENT OF CARMEL McCALLUM DATED 18/12/2017

PN1491

VICE PRESIDENT HATCHER: Mr Seck.

PN1492

MR SECK: Thank you, Vice President.

CROSS-EXAMINATION BY MR SECK�� [3.47 PM]

PN1493

MR SECK: Ms McCallum, you refer to having access to patient histories in 1983 in paragraph 18 of your statement?‑‑‑Yes, I do.

***�� CARMEL MARY MCCALLUM�� XXN MR SECK

PN1494

So I gather from that that was around 1983 was the first time you had access to computers which allowed you to access patient histories. Is that right?‑‑‑That's correct.

PN1495

Tell the Commission how that impacted on the performance of your job as a result of having access to those patient histories?‑‑‑Well, not immediately for me because we were posted overseas but when I came back it meant that we could, for the first time, actually look up a patient and see all their history together rather than have it all logged in a book, which was just line-by-line entry of order of scripts presented at the pharmacy.

PN1496

By having access to that information, how did that impact on your day-to-day job?‑‑‑Well, it meant that we had an accurate history of what we had dispensed to them ready at hand. It wasn't perfect but it was the beginnings of computerisation of dispensing and data collection, being able to keep data on people that was really easy to access.

PN1497

By having that ready to hand, that allowed you to make an assessment of the potential adverse medical interactions which may occur in taking different medicines, is that right?‑‑‑Well, basically yes, but the computers at that stage didn't have any other information. It was just extremely basic, just history. It didn't allow of course - as still you can't unfortunately - access if people have had things dispensed elsewhere but we could actually look and see what people were taking so we could actually see if they had been on something before that may have had an interaction with the current dispensing.

PN1498

When you say you can't tell what other medicines which may have been purchased from other pharmacies, you would obviously have to have a discussion with the patient to ascertain that kind of information?‑‑‑Well, in my experience, I've worked mostly in small pharmacies where people were very loyal customers, so they mostly - most pharmacies I've worked in, I would say, were people who came to me, to our pharmacy, only, where I've been working. It's more loyal customers that don't tend to do - get things dispensed elsewhere anyhow. So - but of course I would have asked at the time if there was anything - if it was someone that wasn't a regular customer, I may have - I would have asked them if they had anything elsewhere. But back in those days, if you're talking way back then, people were not on as many drugs as would be currently and in the last, say, 10 to 20 years when comorbidity has increased, lifestyle diseases have increased, there are more older people on more drugs so it's actually more difficult if people shop at different pharmacies nowadays.

***�� CARMEL MARY MCCALLUM�� XXN MR SECK

PN1499

You really do need to ask them. It's much - it's become much more complicated. There are many more people - because I work largely in areas too where there is a lot of retirees. South coast, I've worked around Port Stephens, Blue Mountains - a lot of retirees and older people and because people are living longer, they are tending to develop more diseases, of course, that is going to happen as people get older and they will inevitably be on more drugs. So we tend to always make sure now if they're not a loyal, regular customer that you would ask them, "Are you taking any other medications?" you would look through all their scrips that they do present to you and make sure there's no interactions. Nowadays that is actually more complicated and more necessary than in the past.

PN1500

You talk about in the past, which I think you're referring to back in 1987 when you returned from overseas?‑‑‑Yes.

PN1501

Part of the job obviously would be having a discussion with the patient to provide them with information and counselling about the appropriate use of the medication?‑‑‑Yes, but I was usually pretty explicit as well about how they should take it by labelling correctly. That is something that is very basic to dispensing. It wouldn't have changed but as I said before, because people are on more medications these days, it's becoming even more essential to make sure that people really understand about how they should take their medications to get the best effect and to of course reduce side effects or be aware of possible interactions.

PN1502

Ms McCallum just follow with me through the questions. I'm going to be talking about the 1980s - not that now at the moment?‑‑‑Okay.

PN1503

So we'll come back to what's happening now later on. If you can answer my questions about what was happening when you returned from overseas in 1987 and onwards, the discussions that you had with patients, you said you would have those discussions but a lot of the time you would have had explicit instructions in the forms of stickers on the medication, that's right?‑‑‑Stickers, I'm trying to think when stickers came in - that was a little bit later.

PN1504

All right?‑‑‑I would have been very explicit with my labelling. Well, it was still the fact that I mostly had - when I owned my own pharmacy especially - very loyal customers and if people came to town, so to speak, to go and see the specialists, then I would have talked to them about what they were dispensed if they weren't a regular customer.

***�� CARMEL MARY MCCALLUM�� XXN MR SECK

PN1505

When you spoke to these new customers as opposed to your regular customers about what is to be - the medication and its use, would you also have a discussion with them about other medications that they were taking at the time?‑‑‑Well, yes, but as I said most people weren't on a lot of medications. I'm talking about - I had skin specialist upstairs so that was usually something that didn't - well, it wasn't essential as far as drug interactions went because there weren't the dangers with the medications that - I know you said don't talk about today - there weren't as many possible interactions because there were fewer drugs. I probably would have - I'm just trying to think of people who would have visited. Mostly it was like a radiology place so I wouldn't have had scripts from them. Skin specialist was the most common at that stage, that we had upstairs in the medical centre where I worked. It was a GP and medical centre so I had regular patients coming from the GPs around town and mostly skin specialist scripts so yes, I don't think interactions were necessarily the most probable thing that I would have been discussing with them at that stage.

PN1506

When you say it wasn't the most probable thing, I think you were saying you did discuss it but it wasn't as much of a concern?‑‑‑I probably didn't with skin things at that stage.

PN1507

How about non-skin-related ailments?‑‑‑Well, then I would have. I would have but as I said, most people weren't on that many drugs that there was that kind of interaction. Probably the most common interaction in those days would have been doctors prescribing say Diazepam with other antidepressants. That would have been probably the most common possible interaction and - - -

PN1508

You wouldn't know that unless you had that discussion with them, would you agree?‑‑‑Well, I would probably ring the doctor before I even spoke to the patient at that stage, if it was for a new script.

PN1509

Right, if it was an over-the-counter medication and it wasn't prescribed by a doctor you would have a discussion with the patient?‑‑‑Yes - even then what was over the counter, which were called S2 drugs in those days, very few would have interacted. There wasn't - a lot of the over-the-counter drugs, apart from, say, cough mixtures where you might have had to discuss with the patient but we didn't actually have - I'm trying to think when ibuprofen came in. that wasn't available over the counter in those days. There was just Panadol, Panadeine. But of course the levels of purchase of that weren't as high either at that time.

PN1510

Would you also in having that discussion with the patient try to ascertain more generally things about their health to give them advice as to the medication?‑‑‑Probably not as much because they were seeing a GP and I would have - well, they weren't as old, they weren't as complicated at that stage. It was not as complicated with the numbers of drugs that people were taking. There weren't the numbers of drugs available and so interactions were rare and I would have discussed it if they were there but - or I would have rung the doctor as well and consulted with the GP.

***�� CARMEL MARY MCCALLUM�� XXN MR SECK

PN1511

Now, I want to take you back to your statement, Ms McCallum. SO do you have the statement in front of you? You refer to workloads increasing in paragraph 21 of your statement. You see that?‑‑‑Yes.

PN1512

Now, in terms of workload - you've worked, I think, according to you in over 50 pharmacies in New South Wales since 1988. Do you think the workload differs from pharmacy to pharmacy depending on a range of different factors?‑‑‑Yes, that would be true to some level.

PN1513

Some of the factors would be how many staff members are working at the pharmacy?‑‑‑Well, even so there have been pharmacies where I have worked where I've dispensed nearly 300 scripts in a day and of course had other consultations with customers and sales items and it can be very stressful.

PN1514

Ms McCallum, I know you've set this out in your statement but I'm just asking you about the factors that would influence the workload that you have as a pharmacist. So I think you agreed that staffing would be one issue. Do you agree?‑‑‑Well, most places I've worked we've worked with the minimum of staff and it has been pretty consistent all day long, working quite - full on.

PN1515

So when you say, "most places", there are some places where you've worked where the staffing would allow you to reduce your workload?‑‑‑Very occasionally.

PN1516

Another factor would be the business of the pharmacy, would you agree?‑‑‑Well, that's why the workloads are high, because they are busy. It's the cat chasing the tail. The numbers of scripts being produced, dispensed, numbers of customers coming in, asking for S3 products - - -

PN1517

VICE PRESIDENT HATCHER: Some pharmacies will be busier than others - - -?‑‑‑Some will be.

PN1518

- - - depending on their location, their demographics, that sort of thing?‑‑‑But from my experience, most pharmacies I've worked in - nearly all of them have been pretty well - you get there, you start working, you work pretty well flat-out all day till you leave.

***�� CARMEL MARY MCCALLUM�� XXN MR SECK

PN1519

MR SECK: You say in page 6 of your statement - it's a very long paragraph, paragraph 21 - I think you made a change to this sentence, that, "There are many more products", that you have to deal with, "since the up-scheduling of many over-the-counter products to schedule 3 and 3R recordable." What does 3R recordable refer to?‑‑‑Well, that's pseudoephedrine and mostly pseudoephedrine - it means drugs which - where we make sure by recording it that there is some - it is a regulation with pseudoephedrine that we put it onto project stop and that way we get a feedback to say that the person has already purchased it somewhere else in that day. It's just making sure that there is some control over the sale of those items.

PN1520

Would it be fair to say that there has been both up-scheduling and down-scheduling of medicines which has occurred throughout your time as a pharmacist since scheduling has been introduced?‑‑‑Yes, but it's only happened in the late '90s and onwards, really. Yes, it didn't happen before that.

PN1521

It didn't happen or just didn't happen as often?‑‑‑I don't remember it happening at all before that.

PN1522

Okay. You also refer to - in your statement, paragraph 22 - different digital dispensing systems, which is paragraph 22?‑‑‑Yes, I see.

PN1523

I gather the point you're making there is because there are different systems in place they have different levels of effectiveness and speed. Is that right?‑‑‑Yes, that's right.

PN1524

That will depend, obviously, on the system used by the particular pharmacy at any particular time?‑‑‑Yes.

PN1525

Now, if you go to paragraph 27 of your statement you say - 26 and 27, I should say - you say as a pharmacist you are required by law to be on the premises at all times?‑‑‑Yes, when you're the only pharmacist there.

PN1526

When you're the only pharmacist there, so I think the example you say is that you have not been able to go to the toilet at various times. So if the toilet is outside the pharmacy are you saying - is it your evidence - that you never went to the bathroom?‑‑‑That wasn't the reason. Generally speaking, people have to go to the loo and if the pharmacy doesn't have one in it then obviously you have to leave to go to - it's usually within a shopping centre - - -

PN1527

Right?‑‑‑ - - - where you may have to go to the public toilets. But there have been days, yes, when I haven't even had time to go, whether it was in or outside the pharmacy.

***�� CARMEL MARY MCCALLUM�� XXN MR SECK

PN1528

That's because of a range of factors, including the fact that the bathroom is outside of the premises?‑‑‑No, no, not including that - it's including the fact that I was so busy that I didn't have a chance to go. Sometimes I also didn't have time to drink properly or eat and I would just not get to the loo all day because I was so busy.

PN1529

You're entitled to breaks under the award, you're aware of that?‑‑‑That's only if you actually have someone to take your place and do the work because we don't make appointments. We have to basically keep working and serving customers, patients, doing scripts as they come in so we don't always have control over that, especially at the end of the year, when it gets busier because of the - as I've mentioned in my submission that people do tend to come and get things as often as they can with the NHS safety net system.

PN1530

You say in paragraph 28 of your statement people - unlike most professions, pharmacists are not able to make appointments for inquiries off the street as people have an expectation that we are freely available at all times, which has always been the situation. So when you say, "which has always been the situation", you're saying that it's always been the case that patients have come into a pharmacy and expect to be able to speak to you about various issues, is that right?‑‑‑Yes, but it has got busier because of overseeing S3 sales, because we're the first line of contact and people do try to come to pharmacies to get information. There have been other things that have come in, like morning-after pill and so on where we need to actually speak to the customer directly and in private. We have to attend to those people are they come in because that is our system but it has got busier over the years. I think because there are more things where a pharmacist is directly required to speak to patients as time has gone on, especially since the down and up-scheduling of the drugs that we mentioned earlier, and we need to give them our full attention and we can't attend to other issues that may be happening in the pharmacy at the time. So you will always have people waiting for scripts as well, while you're trying to talk to patients so it just is - sometimes it's a continuous stream of paying attention to whoever you can at the time.

PN1531

But the way I read your paragraph 28, Ms McCallum, is that the people walking in off the street and having a discussion or appointment with you has been always a feature of working as a pharmacist since you started in 1977. It's really just the number of people and the expectations that people have which has changed. Is that correct?‑‑‑No, not really - it's just the fact that we are busier, we have more - there has been more - since the down-scheduling and up-scheduling and the increase in numbers of scripts and the fact that more people are getting older and on more drugs that we are continually working and that is really the reason. It's just the continuum of the demand of the job.

***�� CARMEL MARY MCCALLUM�� XXN MR SECK

PN1532

Just on paragraph 29 of your statement, Ms McCallum, you say if you were commencing in the profession as a pharmacist now, you would consider not doing it and that is because you don't think you are fairly remunerated. Is that a fair description of what you say there?‑‑‑Well, not only that reason but the fact that it is a very stressful job. You have a lot of responsibility. You are there to give advice and counselling and that part of the job, I actually really love but there are very many demands on us at all times that makes that very challenging and so you end up feeling really quite drained and exhausted and sometimes you even feel that - you feel disappointed. There's not a lot of opportunity in community pharmacy for promotion or we don't have enough professional services or funding for professional services. So there is not that opportunity to actually become more valuable to society, to the community health situation. We could actually be offering more help if we had better funding for professional services and if that happened then I think the job would be more fulfilling.

PN1533

When you say there should be more funding, are you talking about government funding? Is that right?‑‑‑Yes, well, the remuneration from government funding, yes, that would be terrific and pharmacists would really, I think, feel a greater challenge and the ability or the possibility, opportunity, to be more involved in community health.

PN1534

No further questions.

PN1535

VICE PRESIDENT HATCHER: Any re-examination, Ms Knowles?

PN1536

MS KNOWLES: I have one question.

RE-EXAMINATION BY MS KNOWLES�� [4.10 PM]

PN1537

MS KNOWLES: Ms McCallum, when you said that there is not much opportunity for promotion in pharmacy, what did you mean by that?‑‑‑As community retail pharmacist, you go to work, it's - you just arrive, you start working, you work flat-out all day, generally speaking, at nearly every pharmacy I've worked at, and you're just an employee. That's how you feel, especially if you're not working at the same pharmacy for many days and you're not a part of the regular running of the pharmacy. It can be - the fact that you can't be promoted any more than that, in that situation. There is not the opportunity for remunerating people for training and so on, to do more, to contribute to the overall education and keeping the community educated, helping to prevent illness and so on, those requirements that all pharmacists would really love to be more a part of.

PN1538

Thank you, no further questions.

PN1539

VICE PRESIDENT HATCHER: Thank you very much, Ms McCallum. You are excused and free to go?‑‑‑Thank you very much.

***�� CARMEL MARY MCCALLUM�� RXN MS KNOWLES

<THE WITNESS WITHDREW�� [4.11 PM]

PN1540

VICE PRESIDENT HATCHER: Mr Irving and Ms Knowles, is it possible at some stage before the end of the week - or certainly before Friday - that we could get an updated schedule of the wage claim your client's advancing?

PN1541

MR IRVING: Yes.

PN1542

VICE PRESIDENT HATCHER: As I understand it, I think the version in the submissions didn't take into account the last annual wage review increase.

PN1543

MR IRVING: Yes.

PN1544

VICE PRESIDENT HATCHER: Perhaps that could be recalculated so that we know exactly what the - - -

PN1545

MR IRVING: Yes, it will be done.

PN1546

VICE PRESIDENT HATCHER: Thank you. We will now adjourn and resume at 10 am tomorrow morning.

ADJOURNED UNTIL WEDNESDAY, 09 MAY 2018 �� [4.11 PM]

LIST OF WITNESSES, EXHIBITS AND MFIs

KATERINA MARIA MALAKOZIS, AFFIRMED.......................................... PN775

EXAMINATION-IN-CHIEF BY MS KNOWLES............................................ PN775

EXHIBIT #6 STATEMENT OF KATERINA MALAKOZIS DATED 20/12/2017 PN781

CROSS-EXAMINATION BY MR SECK.......................................................... PN783

RE-EXAMINATION BY MS KNOWLES........................................................ PN931

THE WITNESS WITHDREW............................................................................ PN942

CARDIN LE, AFFIRMED.................................................................................. PN948

EXAMINATION-IN-CHIEF BY MS KNOWLES............................................ PN948

EXHIBIT #7 WITNESS STATEMENT OF CARDIN LE DATED 13/12/2017 PN957

CROSS-EXAMINATION BY MR SECK.......................................................... PN961

THE WITNESS WITHDREW.......................................................................... PN1096

LEON YAP, AFFIRMED.................................................................................. PN1101

EXAMINATION-IN-CHIEF BY MS KNOWLES.......................................... PN1101

EXHIBIT #8 WITNESS STATEMENT OF LEON YAP DATED 18/12/2017 PN1109

CROSS-EXAMINATION BY MR SECK........................................................ PN1112

RE-EXAMINATION BY MS KNOWLES...................................................... PN1225

THE WITNESS WITHDREW.......................................................................... PN1231

JENNIFER RUTH MADDEN, AFFIRMED................................................... PN1236

EXAMINATION-IN-CHIEF BY MS KNOWLES.......................................... PN1236

EXHIBIT #9 WITNESS STATEMENT OF JENNIFER RUTH MADDEN DATED 14/12/2017............................................................................................................................... PN1243

EXHIBIT #10 BUNDLE OF AACP DOCUMENTS...................................... PN1262

CROSS-EXAMINATION BY MR SECK........................................................ PN1271

RE-EXAMINATION BY MS KNOWLES...................................................... PN1345

THE WITNESS WITHDREW.......................................................................... PN1351

PHILLIP MILES CLARKE, AFFIRMED...................................................... PN1362

EXAMINATION-IN-CHIEF BY MR IRVING............................................... PN1362

EXHIBIT #11 REPORT OF PROFESSOR PHILLIP CLARKE AND ASSOCIATED DOCUMENTS..................................................................................................... PN1374

CROSS-EXAMINATION BY MR SECK........................................................ PN1381

THE WITNESS WITHDREW.......................................................................... PN1453

CARMEL MARY MCCALLUM, AFFIRMED............................................. PN1462

EXAMINATION-IN-CHIEF BY MS KNOWLES.......................................... PN1462

EXHIBIT #12 WITNESS STATEMENT OF CARMEL MCCALLUM DATED 18/12/2017............................................................................................................................... PN1490

CROSS-EXAMINATION BY MR SECK........................................................ PN1492

RE-EXAMINATION BY MS KNOWLES...................................................... PN1536

THE WITNESS WITHDREW.......................................................................... PN1539