Decision to fund treatments in the community for trauma and medical emergencies, and ketamine for palliative care

Droperidol

Inj 2.5 mg per ml, 1 ml ampoule

Droperidol Medsurge

10

$28.68

Glucose [Dextrose]

Inj 5%, 100 ml bag

Fresenius Kabi

50

$97.00

Glucose [Dextrose]

Inj 10%, 500 ml bag

Baxter Glucose 10%

18

$126.00

Enoxaparin sodium

Inj 100 mg in 1 ml syringe

Clexane

10

$70.91

Methoxyflurane

Soln for inhalation 999.9 mg per g, 3 ml bottle with inhaler device and activated carbon chamber

Penthrox

1

$54.00

Methoxyflurane

Soln for inhalation 999.9 mg per g, 3 ml bottle

Penthrox

10

$276.00

Tranexamic acid

Inj 100 mg per ml, 10 ml ampoule

Tranexamic-AFT

5

$7.99

Ketamine

Inj 100 mg per ml, 2 ml vial

Ketalar

5

$36.23

Strong support for overall proposal.

Reduces inequities in access to urgent and palliative care, particularly for rural communities.

We appreciate the time and effort people have taken to respond to this proposal.

We hear the strong support and anticipated benefits to people living in rural and remote New Zealand.

We are pleased to be progressing this proposal to strengthen access to medicines in response to issues raised by PRIME providers and Lead Maternity Carers.

Improved patient outcomes

Ensures timely access to essential emergency medicines, reduces treatment delays, improves patient safety and outcomes.

We are pleased to hear the support for anticipated benefits to rural people.

Standardisation of emergency medications between PRIME providers and ambulance services reduces clinical risk, enhances interoperability, streamlines rural emergency responses.

We agree that alignment of PRIME treatment protocols with standing orders for paramedics have clinical and safety benefits.

PRIME provider access to tenecteplase and ST-elevation myocardial infarction (STEMI) kits

Call to enhance availability of tenecteplase and STEMI kits for PRIME providers.

Current arrangements for supply of tenecteplase from Health NZ hospitals to PRIME sites would continue as they are now. We understand that aligning the supply of funded tenecteplase with other treatments under this decision would be beneficial for PRIME providers. We continue to work with suppliers of tenecteplase to understand if this is possible.

STEMI kits include tenecteplase, enoxaparin, heparin, clopidogrel, and intravenous metoprolol. These kits are currently supplied by Health NZ hospitals directly to relevant PRIME sites.

Heparin, clopidogrel, and intravenous metoprolol are already funded with no restrictions in the community.

Under this decision enoxaparin will also be funded on PSO for PRIME providers.

Expanding funded PRIME medicines to other providers

Consideration to expanding funded access for PRIME medicines to other rural providers in future.

We’ve shared this feedback with Health NZ for consideration as rural primary health models expand/evolve.

Training, clinical competency and clinical guidelines

Refresher training would be required for PRIME providers to ensure ongoing competence.

Pharmac’s primary role is to fund medicines. Professional regulation, including training, competency, and clinical guidance appropriately sits with professional bodies and clinical leaders.

Hato Hone St John manages PRIME training on behalf of Health NZ. We have shared this feedback regarding refresher training with Health NZ.

Governance and accountability

Ensure medication usage, clinical outcomes, and adverse events tracked within PRIME and shared with Health NZ and ambulance providers to support continuous improvement.

While Pharmac does not hold governance or accountability for clinical data or service oversight, we are supportive of efforts to strengthen monitoring and continuous improvement across PRIME.

We have shared this feedback with HealthNZ.

Improving maternal outcomes

Reduces inequities and maternal outcomes for people who live rurally and/or home birth.

We are pleased that the proposal is supported by key stakeholders and would reduce inequities and maternal outcomes for rural people who home birth.

Availability of tranexamic acid

Ensure availability for all rural providers, not limiting to PRIME providers.

This decision enables intravenous tranexamic acid to be funded for the treatment of PPH irrespective of provider delivering the care (and also funded for PRIME services).

Access via PSO mechanism enables timely access ahead of need.

We are pleased that availability on PSO as proposed would support timely access to treatment.

Training, clinical competency and clinical guidelines

Provide training and education for rural clinicians and midwives.

Pharmac’s primary role relates to funding medicines. Professional regulation, including training, competency, and clinical guidance appropriately sits with professional bodies and clinical leaders.

Health New Zealand publishes current guidelines for the prevention and management of postpartum haemorrhage (PPH), which include the use of tranexamic acid. The guideline is available at Postpartum Haemorrhage (PPH) Prevention and Management | Health NZ [PDF](external link)

Delivery of care closer to home

Reduces barriers for treatment of intractable pain for people receiving palliative care in the community.

We appreciate the support from key stakeholder groups.

We are pleased it is anticipated this decision would improve access for treatment of intractable pain and improve many aspects of treatment for pain management in palliative care in the community.

Unsupportive

Poor evidence for ketamine for intractable pain in palliative care.

This decision would result in funding for ketamine in this indication, providing clinicians with this treatment option if they deem it is appropriate for their patient. Clinicians would not need to use ketamine if they did not consider it appropriate for their patients.

Our clinical advisors are supportive of this proposal.

Oppose funding unless delivered via a specialist service.

We acknowledge that not all clinicians would support access to ketamine without specialist input. We note the broad support from key sector stakeholder groups and do not consider any changes to the original proposal are necessary.

Availability of ketamine

Enable access via PSO mechanism to ensure after-hours access for remote and rural practices.

Ketamine will be funded for PRIME and intractable pain in palliative care indications, on i) prescription  ii) practitioner supply order (PSO) for general practice, and iii) bulk supply order (BSO) for rest homes and hospices.

PSO and BSO enables ketamine to be available for these indications ahead of need.

Training, clinical competency and clinical guidance

Provide clear clinical guidelines for safe use and administration requirements in palliative care.

Pharmac’s primary role is to fund medicines. Professional regulation, including training, competency, and clinical guidance appropriately sits with professional bodies and clinical leaders.

ANZSPM and Hospice NZ have published specialist guidelines that include Ketamine use in palliative care

Aotearoa Specialist Adult Palliative Care Guidelines | Hospice NZ(external link)

It is important that nurse practitioners will be able to prescribe ketamine.

Funding for ketamine is not limited to a particular practitioner type. If a practitioner is legally permitted to prescribe and administer ketamine within their scope of practice, they will be able to access the funded treatment.

Audit and monitor psychological risks.

Pharmac’s primary role relates to funding decisions. Professional regulation, including training, competency, and clinical guidance appropriately sits with professional bodies and clinical leaders. 

Avoid ketamine for chronic pain management.

Under this decision ketamine will be funded for PRIME and intractable pain in palliative care indications only.

Risk ketamine cannot be safely and effectively used unless delivered within or from advice from a specialist service.

Recommend ketamine is on a Special Authority with funding restricting to by or on the recommendation of a specialist palliative care service.

Pharmac uses access criteria to target funding to people who would receive the most benefit from treatment. It is not Pharmac’s role (through access criteria) to provide clinical guidance. 

Pharmac has moved away from limiting funding of medicines access to a specific service or prescriber type. Funded access is determined by the person’s clinical condition (indication), ensuring treatment is directed to those who most need it. 

Further information is available in our Access criteria policy

 The proposed endorsement limits funding to appropriate clinical indications.

 Competency to prescribe and use medicines remains the responsibility of the relevant prescriber, supported by their professional organisations. 

ANZSPM and Hospice NZ have published specialist guidelines that include Ketamine use in palliative care

Aotearoa Specialist Adult Palliative Care Guidelines | Hospice NZ(external link) 

Funding info required for community pharmacists.

Pharmacists will be notified of the funding changes through our monthly Pharmaceutical Schedule update processes. 

Safe storage and monitoring

Potential for misuse and diversion.

Ketamine is a controlled drug under the Misuse of Drugs Act, and its prescribing and handling must comply with the regulatory requirements set out in that legislation. Professional responsibilities, including safe prescribing, secure storage, and preventing misuse or diversion sit with authorised prescribers and service providers. Funded access is directed by the clinical indication, to direct access only to those who meet the eligibility criteria. 

We anticipate relatively small and contained ketamine use for these indications in the community. We expect that approximately 75 people a year would receive ketamine for the treatment of intractable pain in palliative care. There are approximately 70 rural general practices who provide PRIME services.