Editor's Note: Well known pharmacy researcher,Con Berbatis, has now completed the recommendation from his ground-breaking Australian pharmacy survey in 2002.
It has been hailed as one of the most complete surveys ever undertaken, primarily because of the large number of respondents. At a time when pharmacy is under a major threat from Woolworths, it is this type of information that can form the basis of suitable national strategies to guide pharmacists through the ever increasing complexity of pharmacy practice.
For more details, you may need to visit the website of the survey, found at: http://www.curtin.edu.au/curtin/dept/pharmacy/survey/index.html
You shold bookmark this page for future reference.

Most of the following recommendations correspond to a section and a table with data in this report, both of which are cited. The national and state bodies of pharmacy referred to in the recommendations to implement the recommendations are listed in the glossary (Section 7).

Methodology
Recommendation 1: Australia's community pharmacies were stratified in a national survey for the first time according to the PhARIA zones 1 to 6 (Section 1.4) . Approximately 81% of Australia's community pharmacies are in PhARIA zone 1 which skewed the sampling process and required much larger samples than planned , much more work and higher costs than budgeted to overcome the difficulties (Section 1.4.1.1) .
Systems other than the PhARIA system should be carefully evaluated for stratification purposes in future national surveys of community pharmacies . Other available systems of stratification such as SEIFA should be compared with the PhARIA for stratification.

Recommendation 2: It was found many pharmacies in the lists of registered pharmacies provided by state pharmacy authorities were invalid because they were no longer operating, were not community pharmacies, were duplicated, or had operated for a fraction of the whole year (Section 1.4.2) . During the 12 months ending 30 June 2002 it was found just 4447 approved pharmacies operated for the full 12 months (Section 1.4.7) . This total is much smaller than the total number of 4824 pharmacies in the pool from which the samples were drawn and smaller than previously reported national totals of pharmacies which caused unnecessary difficulties for calculating the national estimates.
In order to make accurate national estimates the months of operation of pharmacies in the subject year should be included in future questionnaires to accurately ascertain the number of full time equivalents of community pharmacies operating during the survey period.

Recommendation 3: For a number of the questions the results were skewed requiring various statistical and other methods of adjustment (Section 1.4.7) . With respect to analysis by Pharia zone the results obtained in this survey provide reference values for a range of questions.
If the PhARIA system is applied to future national surveys using a similar questionnaire, then
a) the two separate best estimates should first be calculated for the results of pharmacies PhARIAS 1 and PhARIAS 2-6 so that the corresponding future questions reflect the ranges of results around the respective best estimate; and
b) that separate pilot surveys of Pharia 1 and Pharias 2-6 pharmacies be conducted with questionnaires reflecting 'regular' ranges of estimates around the respective best estimate means in a) above.

Recommendation 4: Many questions in the questionnaire contained the terms "number of clients" or "number of patients" in relation to prescription-related activities (Section 1.4.7) . These terms need to be standardised to "number of dispensing occasions" which requires a number of key parameters.
To facilitate more accurate national estimates of the activities occurring in Australia's community pharmacies the national bodies of pharmacy should arrange to obtain from the Drug Utilisation Sub-Committee in the Department of Health and Ageing (a) the mean number of items dispensed per dispensing occasion, (b) the percentage of repeats per dispensing occasion and (c) the percentage of prescription items dispensed for non-ambulatory .

Database results

Recommendation 5: Pharmacy respondents reported they spent a minimum of 6.8 hours per month on continuing pharmacy education activities which appears to be at least twice the level reported by pharmacists in Northern Ireland and England (Section 3.1, A). It was difficult to compare continuing pharmacy education activities from statistics reported by interstate and overseas bodies of pharmacy. This will expedite more accurate time-series, interstate and international comparisons. Refer Section 3.1, Table D-A1.
National and State pharmacy bodies in Australia should cooperate to standardise and report continuing pharmacy education activities by the hours per month spent in these with appropriate weighting of the activities by representative samples of pharmacists. These bodies should verify the higher levels of continuing pharmacy education activities reported by Australian pharmacies compared to UK pharmacists because of the important implications for the remuneration of pharmacy services .

Recommendation 6: There was no relationship evident between the prevalence of enhanced pharmacy services reported by community pharmacies and the recognised official priorities in health (Section 3.1, B). Refer Table D-B7-1.
National and State bodies of pharmacy and university departments of pharmacy should emphasise the teaching of enhanced pharmacy services by reference to Australia's national health priorities (Section B).

Recommendation 7: The marked variations in the prevalence of enhanced pharmacy services reported by community pharmacies with trained staff may reflect interstate differences in the training programs available for enhanced pharmacy services (Section 3.1, B). Refer Table D-B7-1.
National and State bodies of pharmacy should cooperate to produce and offer standard pharmacy training programs for enhanced pharmacy services should be adopted nationally.

Recommendation 8: There was no relationship evident between fees charged by pharmacies for enhanced pharmacy services and the availability of trained staff for these services (Section 3.1, B). Refer Table D-B7-1.
National and State bodies of pharmacy should plan the systematic evaluation of enhanced pharmacy services to determine the basis for and level of their remuneration by pharmacies with trained staff.

Recommendation 9: Wound care is an outstanding example of an enhanced pharmacy service which is practiced by trained staff in a comparatively high percentage of Australia's pharmacies and is growing at a high rate (Section 3.1, B). Refer Table D-B7-1.
National and State bodies of pharmacy should assess the training programs and promotional methods used for the remarkably successful adoption of wound care services in pharmacies for their application to other enhanced pharmacy services which rank highly in Australia's national health priorities.

Recommendation 10: Many enhanced pharmacy services were reported from low percentages of pharmacies in PhARIA zones 5 and 6 where many under-privileged aborigines reside (Section 3.1, B). Refer Table D-B7-1.
National and State bodies of pharmacy should produce suitable intensive training programs for enhanced pharmacy services to be implemented and/or made more accessible to pharmacists working in pharmacies in PhARIA zones 5 and 6.

Recommendation 11: Pharmacies reported the serious barriers to performing enhanced pharmacy services were "lack of time", "shortage of pharmacists" and "no extra remuneration" (Section 3.1, C). Pharmacies rejected that enhanced pharmacy services were not part of their work.
National and State bodies of pharmacy should investigate and produce intensive structured training programs for specific enhanced pharmacy services most likely to be remunerated in the future to help to overcome the reported barriers to their adoption by pharmacies . Refer Table D-C8.

Recommendation 12: The facilitators reported by pharmacies for performing enhanced pharmacy services were "dedicated study time", "accreditation", "closed counselling areas" and "access to patient notes" (Section 3.1, C). Refer Table D-C9.
National bodies of pharmacy should promote remunerated, accredited programs for enhanced pharmacy services and closed counselling areas and access to clients' clinical histories for the higher adoption and competent performance by community pharmacies of enhanced pharmacy services in order to respond to those facilitating factors for these services reported by pharmacies .

Recommendation 13: High percentages of Australia's community pharmacies reported the weekly provision of dose administration aids and supervised dosing without charging (Section 3.1, D). Refer to Tables D-D11A and D-D11c.
National bodies of pharmacy should organise and publicise the cost-effectiveness evaluations of the provision of dose administration aids and supervised dosing by pharmacies in order to establish acceptable remuneration for these services. University departments of pharmacy should emphasise the benefits and procedures of dose administration aids and supervised dosing in the routine teaching of pharmacy practice.

Recommendation 14: Approximately 40% of Australia's pharmacies declined dispensing prescription drugs for at least one patient weekly because of inappropriate drug, dose or suspected interaction or contraindication, or for prescription defects (Section 3.1, D). Another 30.7% of pharmacies declined dispensing prescription drugs for at least one patient weekly for suspected adverse drug effects. Overall, 1.25% of patients dispensed 216 million prescription items yearly were reported to have had their prescribed medications declined for the above reasons. Refer to Table D-D12.
These reported rates of intervening in the dispensing of prescribed medicines in pharmacies should be verified by direct observation in a representative sample of pharmacies and submitted to pertinent agencies by national bodies of pharmacy as they provide strong evidence for the vigilance by pharmacies in preventing the inappropriate prescribing and adverse effects of prescription medicines , and detecting legally defective prescriptions over-the-counter medicines.

Recommendation 15: Community pharmacies reported counselling in the past 12 months a minimum of 3.17 million patients with low or poor English speaking ability about their prescription medicines (Section 3.1, D). Refer to Table D-D13a.
National bodies of pharmacy should verify the extent and evaluate the provision of counselling to patients with poor English speaking ability for prescription-related activities so that community pharmacies are adequately remunerated for providing this service.

Recommendation 16: Low percentages of Australia's community pharmacies reported the use of clinical testing and the application of laboratory results to the assessment of the effects of prescribed drugs in patients (Section 3.1, D). Refer Table D-D13c.
National bodies of pharmacy should investigate and produce software programs for interpreting laboratory results in routine pharmacy practice to enhance the evaluation of effects of prescribed medications .

Recommendation 17: Relatively low percentages of community pharmacies reported performing primary care multidisciplinary care plans, case conferences or case health assessments compared to the percentage performing home medicine reviews (HMRs) or medication management reviews in residential age care facilities (Section 3.1, E). Refer Table D-E14d.
National bodies of pharmacy should consider programs for enhancing the ability of accredited pharmacists top participate in primary care medication review processes to enhance their wider adoption by community pharmacies.

Recommendation 18: Pharmacies reported that the rate of self-medication activities for the management of minor ailments for clients was exceeded by the provision of primary health care activities including issuing over the counter medications, verbal and printed information and referral to GPs and other health workers (Section 3.1, F). This ratio of self-medication to primary care activities appears to differ to that evident in pharmacies in other developed countries and has strong implications for the control of pharmacist-only and pharmacy medicines and the education and training of student and graduate pharmacists and pharmacy staff. Refer Table D-F15a.
National bodies of pharmacy need to verify by direct observation the ratio of self-medication and primary health care activities occurring in a representative sample of community pharmacies .

Recommendation 19: Pharmacies reported estimated yearly totals of 36.97 million self-medication and 41.23 million primary health care activities (Section 3.1, F). These statistics far exceeded those reported for pharmacies by the 2001 National Health Survey .These services do not currently attract remuneration for pharmacies. Refer Table D-F15a.
National bodies of pharmacy need to verify the statistics and organise cost-effectiveness evaluations of self-medication and primary health care activities in Australia's pharmacies in order to accurately represent the magnitude of the national contribution to health care by pharmacies , the potential costs savings to Australia's health system and the possible remuneration of community pharmacy services .

Recommendation 20: Pharmacies reported an estimated 4.19 million clients yearly with ailments were referred to GPs compared with 1.77 million referred to other health workers (Section 3.1, F). Refer Table D-F15a.
National bodies of pharmacy should verify the high rates of referrals of clients with ailments by pharmacies to general practitioners and organise the evaluation of referral forms in pharmacies in order to lay the basis for remunerating referrals by pharmacies.

Recommendation 21: Pharmacies reported an estimated 10.26 million clients yearly with ailments were provided with printed information (Section 3.1, F). Printed information is a widespread form of conveying health information and needs to be evaluated singly and in combination with other methods in order to quantify the impact on specific health outcomes. Refer to Table D-F15a.
National bodies of pharmacy should plan the cost-effectiveness evaluation of printed information provided in pharmacies for clients with ailments.

Recommendation 22: Pharmacies reported an estimated total of 0.86 million clients yearly were suspected of misuse of dependence-producing over-the-counter medicines of whom 0.63 million were refused supply of these medicines (Section F). Refer to Table D-F15b.
The high rates of intervening in the supply of over-the-counter reported by pharmacies should be verified and submitted to pertinent agencies by national bodies of pharmacy as they provide strong evidence for the vigilance by pharmacies in preventing the misuse of over-the-counter medicines.

Recommendation 23: 16% of Australia's pharmacies reported not having vaccine refrigerators which comply with pharmacy standards (Section 3.1, G). Refer to Table D-G16.
National bodies of pharmacy should ascertain the standards of vaccine refrigerators used in pharmacies nationwide for their compliance with recognised standards. Refer

Recommendation 24: Pharmacies reported that they initiated non-prescribed medicines for preventive purposes in more than 5.8 million undiagnosed clients over 12 months (Section 3.1, G). Refer to Table D-G17.
National bodies of pharmacy should obtain further statistics on and plan a cost-effectiveness evaluation of pharmacies in providing non-medically prescribed medicines for preventative purposes.

Recommendation 25: Clinical testing for screening undiagnosed patients were reported to occur in pharmacies which engaged nurses at rates of 2- to 20-fold those of pharmacies which did not engage nurses (Section 3.1, G). Refer to Table D-G19.
National bodies of pharmacy should identify those pharmacies which engage nurses to provide screening activities of undiagnosed patients in order to compare with these activities with those pharmacies which do not engage nurses.

Recommendation 26: Up to 60% of Australia's pharmacies reported providing harm reduction activities daily including methadone dosing, needle supply and issuing benzodiazepines and other drugs according to patient contracts with prescribers (Section 3.1, H). Studies have shown that the provision of these services by pharmacies in Australia and other developed countries are widespread and efficient . Refer to Table D-H19a.
National bodies of pharmacy should examine the systematic and appropriate remuneration of pharmacies active in prescriber contracts , supervised dosing and other harm reduction services.

Recommendation 27: Pharmacies reported detecting a minimum estimated 13,519 patients with forged prescriptions and 23,391 'doctor shoppers' in the previous 12 months (Section 3.1, H). These appear to be the highest rates of detecting forgery and 'doctor shoppers' of prescribed opioids and psychostimulants ever reported by pharmacies. Refer to Table D-H19b.
National bodies of pharmacy should verify the above rates of detection of fraudulent prescriptions for Schedule 8 drugs as they suggest high vigilance in pharmaciess in dispensing these agents or/and extraordinarily high rates of Schedule 8 prescription fraud in Australia.

Recommendation 28: Australia has very high rates of the consumption of prescribed opioids and psychostimulants compared with other developed countries and the results of their fraudulent obtention and misuse (Section 3.1, H) suggest current legislation is defective in facilitating the online access by pharmacies to the medication histories of these patients and taking effective actions to stem the misuse of prescribed Schedule 8 agents.
National and State bodies of pharmacy should immediately press for legislation requiring patients prescribed Schedule 8 drugs to be limited to one medical and one pharmacy provider of these agents and permit medication histories to be accessed online and discussed by these providers prior to dispensing of these drugs.

Recommendation 29: Pharmacies reported they referred more than 40,000 clients per 30 days to complementary therapists (Section 3.1, I). Refer to Table D-I20.
The Pharmaceutical Society of Australia should include guidelines in the Australian Pharmaceutical Formulary and Handbook for the referral of clients to complementary therapists.

Recommendation 30: Pharmacies reported that they referred approximately 15,000 clients per 30 days to aromatherapy, homeopathy and iridology practitioners (Section 3.1, I). Refer to Table D-I20.
Pharmacy Boards in each jurisdiction, the Council of Pharmacy Registering Authorities, the Pharmaceutical Society of Australia and University departments of pharmacy should assess and where necessary act decisively on the questionable referral of clients to complementary practitioners.

Recommendation 31: High percentages of Australia's pharmacies reported the daily use of a wide variety of information, facilities and resources for patient care (Section 3.1, J). Refer to Table D-J21.
National bodies of pharmacy should formulate standard methods for comparing the frequency of use and the cost-effectiveness of outcomes of information resources in pharmacies applied routinely in practice to patient care.

Recommendation 32: Just 7.8% of Australia's pharmacies reported daily or higher use of web-based drug information facilities (Section 3.1, J). Refer to Table D-J21.
The Pharmaceutical Society of Australia and University departments of pharmacy should review their teaching and training programs for pharmacy students and practitioners to ensure the convey the superior benefits of web-based facilities compared with other forms of drug information facilities in patient care.

Recommendation 33: 89.2% of Australia's pharmacies reported Pentium processors but only 4.2% reported having broadband facilities in their dispensary computers (Section 3.1, K). The technological requirements for dispensary computers are changing rapidly in relation to pharmacies participating in the MediConnect system planned to be introduced in 2005. Refer to Table D-K22a
National bodies of pharmacy should ensure the results of ongoing MediConnect trials in pharmacies are well so pharmacies can rationally plan to install the correct computer facilities and enhancements .

Recommendation 34: More than 10% of pharmacies reported they had web sites which offered medication-related activities (Section 3.1, K). Refer to Table D-K22b.
The Pharmaceutical Society of Australia and pertinent bodies of pharmacy should organise an evaluation of existing websites against standards in the Australian Pharmaceutical Formulary and Handbook and other appropriate standards .

Recommendation 35: 34.3% and 24.4% of pharmacies reported they expected respectively internet sales of over-the-counter and prescription medicines would depress their sales of these medicines by 2004 (Section 3.1, L). Joint actions have been taken in 2003 by national bodies of pharmacy in the USA and Canada on the basis of safeguarding consumers from preventable adverse effects of drugs obtained through the internet. Refer to Table D-L24.
National bodies of pharmacy should review actions taken in North America to curtail the internet sale of prescription medicines by pharmacies and other sources.

Recommendation 36: 93.1% and 75.7% of pharmacies agree respectively the telephone is the best form of technology for liaising with doctors and patients about health care (Section 3.1, L). Telephone counselling has proven for two decades to be the most cost-efficient technology in improving the care of patients with chronic disorders. Refer to Table D-L24.
National bodies of pharmacy should plan controlled studies of telephone counselling by community pharmacies in for example patients discharged with treated mental disorders who are known to have high rates of relapse and readmission into hospitals.

Recommendation 37: The most common settings of pharmacies were city, suburban or town shopping strips (41.4%) , followed isolated shops (23.5%) and 18.7% in neighbourhood, 6.3% in medical and 4.8% in regional shopping centres (Section 3.1, M). The locations and hours of opening of pharmacies are important for assessing changing patterns in the location of pharmacies and accessibility to pharmacy services by consumers but it is difficult to ascertain these factors because of the lack of standard definitions and the lack of information on the hours of opening and pharmacy settings. Refer to Tables D-M25b and D-M25c.
The Pharmacy Guild of Australia and other national bodies of pharmacy should agree on standard definitions for the locations of pharmacies and appropriate methods of weighting access to these locations by the public .

Recommendation 38: The retail, storeroom and dispensary section were the largest in area and enclosed counselling and forward pharmacy sections the smallest (Section 3.1,M) . These data are the first known national data on the internal arrangement of pharmacies and have important ramifications on the performance of certain services ( Sections 3.1 C, F and H). Refer to Table D-M26.
The Pharmacy Guild of Australia and other national bodies of pharmacy should agree on standard definitions for the analysis of sections in pharmacies and perform surveys of representative samples of pharmacies in order to monitor the trends in the internal structures of pharmacies.

Recommendation 39: Owners and managers reported they spent up to 30.9 of their 41.7 hours per week in dispensaries and 21% of Australia's pharmacies reported having non-pharmacist retail managers (Sections 3.1,M) . These are important indicators of the involvement by pharmacists in patient care activities. Refer Tables D-M29b, D-M32a and D-M32b)
The Pharmacy Guild of Australia and other national bodies of pharmacy should agree on standard definitions for the analysis of staff in pharmacies and perform surveys of representative samples of pharmacies in order to monitor the trends in the internal structures of pharmacy staff.

Recommendation 40: The national survey of British pharmacies found statistically strong relationships between pharmacists rather than pharmacies and the performance of specialist or extended pharmacy services whereas these Australian results pointed more to certain pharmacy characteristics significantly related to the performance of enhanced and other specialist services in pharmacies (Section 4 ). These results have strong implications for national policies on the development of professional services in pharmacies but they require hypothesis testing with the application of logistic regression analyses to define these relationships. Refer to Table D4.1.
The Pharmacy Guild of Australia and other national bodies of pharmacy should engage further logistic regression analysis be conducted to ascertain the relationship between pharmacy factors including area, group membership and the implementation of enhanced pharmacy and other specialist services on a national basis.

Recommendation 41: Statistically significant relationships were found between certain pharmacy characteristics and barriers and facilitators to taking on enhanced pharmacy services which is the first time such relationships have been analysed and reported (Sections 5.1 and 5.2) . The statistical analyses were limited t-test and chi-squared tests . Refer to Tables D5.1 and D5.2.

The Pharmacy Guild of Australia and other national bodies of pharmacy should engage further logistic regression analysis be conducted to continue the statistical analysis to define the pharmacy variables and ascertain the associations between pharmacist variables and the performance of enhanced pharmacy services.
Pharia comparisons between pharmacies in Pharia zones and services were limited and standardisation is required before deciding policy in certain areas.

Recommendation 42: Statistically significant relationships were found between pharmacy characteristics inferring statistically strong relationships between larger, busier pharmacies and the use communication technologies (Section 5.3) . Refer to Table D5.3.
The Pharmacy Guild of Australia and other national bodies of pharmacy should engage further logistic regression analysis be conducted to continue the statistical analysis to define the pharmacy variables such as Pharia zone, related to the use or impact of technologies on the performance of specified patient care activities and the impact on the sales of prescribed and over-the counter medicines.

Recommendation 43: The effect of the location of pharmacies in certain PhARIA zones especially remote rural pharmacies in PhARIA zones 1 and 2 were referred to in Sections 3 A to M and tested statistically (Sections 4 and 5). Refer Tables 5.1,5.2 and 5.3.
The national bodies of pharmacy should engage statistical analysis in order to standardise the data for pharmacies in the rural and remote Pharia zones and extend the statistically analyses to test relationships between Pharia location and services provided.