I remind members, witnesses and those in the Visitors Gallery that all mobile telephones should be switched off for the duration of this meeting because they interfere with the broadcasting of proceedings and cause unnecessary disturbance to staff members' headsets.
Apologies have been received from Deputies Ciara Conway, Peter Fitzpatrick, Mary Mitchell O'Connor, Caoimhghín Ó Caoláin and Senator Imelda Henry.
I must leave in about five minutes because the topical issue I raised will be taken in the Dáil.
Thank you Deputy. I welcome the viewers who are watching the proceedings of this meeting live on the UPC network and the Oireachtas website. It is important that we reach out to people. It is good to know it is being shown on the Oireachtas website and also on UPC.
We are discussing the role of the pharmacy sector in Ireland and I thank Senator Colm Burke who requested that we hold this meeting before the summer recess. I welcome the representatives of the Irish Pharmacy Union, Mr. Daragh Connolly, vice president; Mr. Bernard Duggan, honorary treasurer; Mr. Darragh O'Loughlin, secretary general and Ms Pamela Logan director of pharmacy services, IPU and thank them for being here this afternoon. The role of the pharmacist has grown and evolved in the past number of years, with the pharmacist providing significant support as well as additional services to patients and clients across the community, both urban and rural.
Pharmacists provide huge support for patients and people across urban and rural communities. In addition to dispensing medicines, they also provide additional services. I thank the delegates of their representative body, the Irish Pharmacy Union, for being here. We will discuss a variety of members' interests and issues of concern.
Before we begin, I draw attention to the important position on privilege. Witnesses are protected by absolute privilege in respect of the evidence they are to give to the committee. However, if they are directed by it to cease giving evidence on a particular matter and continue to do so, they are entitled thereafter only to qualified privilege in respect of their evidence. They are directed that only evidence connected with the subject matter of these proceedings is to be given and asked to respect the parliamentary practice to the effect that, where possible, they should not criticise or make charges against a person or an entity by name or in such a way as to make him, her or it identifiable. Members are reminded of the long-standing parliamentary practice to the effect that they should not comment on, criticise or make charges against a person outside the Houses or an official, either by name or in such a way as to make him or her identifiable.
I apologise for my voice, as I have a chest infection. My local pharmacist took good care of me yesterday. I invite Mr. O'Loughlin to make the opening presentation.
I thank the Chairman and the Members of the Oireachtas who have taken the time to listen to what we have to say. The Chairman introduced those of us who are here as delegates, but I would also like to mention that our colleague, Mr. Jim Curran, the Irish Pharmacy Union's director of strategy and communications, is in the Visitors Gallery. After we have made a brief presentation, we will be happy to take questions on the content of the presentation or any other issue that is relevant.
Some members will be in and out of the meeting because of a vote at the Select sub-Committee on Finance. I apologise for this. Deputy Caoimhghín Ó Caoláin, Sinn Féin's Spokesperson on health, has asked me to pass on his apologies for not being present. He cannot be here because he has another duty in the Chamber.
The Irish Pharmacy Union is the professional representative and leadership body for community pharmacists in Ireland. We are involved in the retail pharmacy sector that people see in every town, village and community. Our mission is to promote the professional and economic interests of our members. Community pharmacists in Ireland are highly trained health care professionals and extremely accessible to the general public. Some 85 million individual visits are made by citizens, consumers and patients, to Irish pharmacies every year.
As a result of the increasing demand for health services and the shrinking resources in the sector, the health system is under unprecedented pressure. It is near breaking point in many respects. Hospitals are overstretched and general practitioners are struggling with their existing workloads. According to GPs, their workload will increase dramatically with the introduction of universal health care and universal access to GP care. The current shortage of GPs is unlikely to be solved in the short term, given that over 1,000 Irish-trained GPs have taken up work in the UK health service since 2009. As the population of Ireland grows and ages, there will be additional pressure on the health care service.
Similar problems have been experienced in other countries and solutions have been found. When demand for GP services exceeded the available capacity in England, Scotland and Canada, the unique skills and expertise of pharmacists were used to enhance access to health care. At the beginning of the year the UK Royal College of General Practice and the College of Emergency Medicine, both of which are based in London, estimated that one in seven GP visits in the United Kingdom - equating to 51 million visits annually - and one in 12 attendances at accident and emergency departments could be dealt with by pharmacists, the health professionals best placed to offer advice and treatment for minor ailments. Based on these statistics, the implementation of a pharmacy-based minor ailments scheme in Ireland could ease the pressure on GP services sufficiently to allow GPs to provide the additional 4 million consultations which they have estimated will result from the roll-out of free GP care.
Our proposals are not just based on alleviating the workload of GPs because patients would benefit, too. According to data from Scotland, in-depth medicine use reviews conducted by pharmacists with patients suffering from chronic illnesses who were taking a multitude of medications reduced hospital readmission rates by one third. In Canada the scope of practice of pharmacists has been extended to include chronic disease management. This involves monitoring the condition of patients with chronic illnesses; renewing and adjusting their prescriptions, where appropriate, to ensure tighter control of their symptoms; and delivering better treatment outcomes. The extension of pharmacist services in these countries, in response to the shortage of GPs, has resulted in better access to health care and substantial reductions in morbidity and mortality rates from illnesses such as heart disease and diabetes.
Irish pharmacists have successfully introduced a pharmacy-based flu vaccination service in the last three winters. This has shown that pharmacists have the ability to deliver professional health care services outside what might be considered usual pharmacy services. Evidence for the benefits of the improved convenience and accessibility pharmacists provide is seen in the fact that 24% of people vaccinated in a pharmacy had never availed of the flu vaccine previously, even though 85% of them were in an at-risk category. The number of flu vaccinations carried out in community pharmacies doubled between the winter of 2010-11 and the winter of 2011-12 and doubled again between that winter and last winter. More and more patients are seeing convenience as a key driver of vaccinations.
At the beginning of Lent this year the IPU, through its member pharmacies, introduced a smoking cessation service, which was launched by the Minister for Health. This service has been broadly welcomed as making a significant contribution towards the ultimate goal of achieving a tobacco-free Ireland. Public surveys have shown that pharmacists rank second only to nurses as the health care professionals most trusted by the public. Despite this, Ireland, unfortunately, continues to lag behind other countries when it comes to allowing pharmacists to offer the additional services people want. Irish pharmacists are willing, ready and able to help to alleviate pressure on GP surgeries and hospitals by providing a broader range of health care services for patients and the public, in line with what is happening in other countries. Nobody is trying to reinvent the wheel.
I would like to refer to two specific services that could be introduced quite easily and which would be of immediate benefit to patients and the State. The primary aim of a minor ailments scheme would be to allow medical card patients to receive treatment for common ailments free of charge directly from their local community pharmacies. Such a scheme would be cost-neutral to the Exchequer because these patients are already entitled to receive prescribed medicines free of charge with their medical cards. Community pharmacists deal every day with minor ailments as part of their normal practice. They give advice to people on how to treat self-limiting conditions. They work with the public to distinguish between minor ailments and illnesses that have the potential to be more serious. They recommend effective treatments that can be secured without a prescription. As a result, they help to play a role in keeping these minor ailments out of the GP surgery. Furthermore, they refer to GPs, where appropriate. If a medical card patient wants to access a non-prescription medicine for a minor ailment, he or she has to go to the GP to get a prescription. The proposed minor ailment scheme would allow medical card patients to access non-prescription medicines directly from pharmacists without the need to go to the doctor.
The IPU strongly welcomes the recent announcement by the Health Products Regulatory Authority, formerly known as the Irish Medicines Board, that it has drawn up a list of 12 medicines which should be switched from prescription-only to non-prescription status. This will increase the options for patients and consumers in managing their health care with the advice and support of their pharmacists. We hope to see the list published within the next two weeks. The implementation of a national minor ailments scheme, using that list as well as existing non-prescription medicines, would benefit patients by providing greater and easier access to health care. It would benefit the health service by targeting resources at where they are needed and would benefit GPs by freeing up their time to deal with patients who have more serious or chronic illnesses that require GP time.
The second service we are proposing is a medicine use review service which would be useful in assessing people's compliance with their medication regimes and improving their medicine-taking through concordance. The Joint Committee on Health and Children recommended in its report on the adverse side effects of pharmaceuticals that the role of the pharmacist in community health should be expanded and provision should be made for regular medication reviews for all patients. International evidence confirms that the introduction of medicine use reviews provided by pharmacists has improved health outcomes, enhanced quality of life and reduced the requirement for hospital care.
The objective of any review of the use of medicines and expenditure on medicines must be to ensure better outcomes for patients and maximise value for money. The introduction of a medicines use review service delivered through community pharmacy delivers on both of these objectives.
Medicines use reviews are an advanced pharmacy service in England and Scotland and their benefits are evident. As I indicated, the medicines use reviews conducted by pharmacists in Scotland with elderly patients who take multiple medicines have reduced hospital readmission rates by more than 30%, resulting in significant improvements in quality of life for the individuals in question and dramatic savings in the cost of their health care. Similar services are also available in pharmacies in the United States, Australia and New Zealand.
In addition to the two services I have described, which could be implemented most easily because they do not require regulatory or legislative change, the role of pharmacists in providing health checks, health promotions and vaccinations could be expanded. As I stated, given that pharmacists provide vaccinations against influenza, there is no reason they should not be permitted to provide other vaccinations, where appropriate. Other services that could be provided by pharmacists include new medicine services, which would involve assisting people who are starting on a new medicine for a chronic condition to understand the medicine, obtain the best outcome from it and ensure they take it; chronic disease management, which would involve working as part of a multidisciplinary team or in collaboration with a patient's general practitioner and other health care professionals to help the person to manage his or her chronic illnesses; anti-coagulation services, which would plug a significant gap whereby people who are on warfarin and other anti-coagulant drugs do not have access to appropriate monitoring facilities in large parts of the country; monitored dosage system services to enhance concordance with medication; and a dispose of unused medicines properly, DUMP, scheme, which is a way of getting unnecessary and unused medication out of homes. Allowing pharmacies to provide these services would improve access to professional health care; reduce overall Exchequer spending on health care; ease some of the existing burden on general practitioner services, thus freeing up crucial resources; and improve health outcomes for patients and members of the public.
I propose to raise a couple of regulatory and other issues. Pharmacy registration fees in Ireland are the highest in Europe and possibly the world. Pharmacists' income has been cut repeatedly through the Financial Emergency Measures in the Public Interest Act and other Government initiatives. Despite the publication some years ago of a Forfás report on regulatory costs which recommended a review of Pharmaceutical Society of Ireland, PSI, registration fees for pharmacies, fees remain at excessively high levels and far out of line with other countries. They are, for example, almost ten times higher than equivalent fees in the United Kingdom. It is, therefore, high time this issue was tackled.
Under the Pharmacy Act 2007, the Pharmaceutical Society of Ireland, the regulator of pharmacists and pharmacists, has fitness to practise and regulatory responsibilities. Pharmacists are frequently prosecuted before the District Court for the same breaches of regulation for which they have faced internal fitness to practise proceedings, even in the case of technical breaches where there is no risk to patient safety. In addition, in less serious cases, when the fitness to practise process has concluded and a pharmacist has been sanctioned by way of admonishment or censure, the outcome is published on the website of the Pharmaceutical Society of Ireland. There does not appear to be a time limit on the period for which a notice remains on the website, which means, in effect, that the punishment is open-ended and, as such, unjust and inequitable. The Pharmacy Act has been place for almost seven years and the fitness to practise process for the past five years. This is an opportune time to assess the manner in which the Act is being implemented, in particular the fitness to practise provisions, to ensure the system is fair, equitable, transparent, efficient and cost-effective.
Under the Pharmacy Act 2007, the Pharmaceutical Society of Ireland may not register a pharmacist who is an undischarged bankrupt. In response to questions from members of this committee - the IPU is grateful to the joint committee for the interest it has taken in this issue - the Minister stated that amendments to the Act, including an amendment to the relevant section, are being examined and will be considered for inclusion as part of any future amendments to the Act. However, given the increasing incidence of personal insolvency among all sectors of society, it is high time an amendment was introduced to allow an insolvent pharmacist to continue to practise his or her profession and earn a living. We ask that the joint committee keep this matter on the agenda until it has been resolved and the Act amended.
It is our intention, as a profession, to propose positive solutions to some of the problems and deficiencies in the health system, with a view to providing accessible, convenient and cost-effective health care services for patients and members of the public and, where possible, relieving pressure on other parts of the health care system.
I thank members again for their time and attention and for giving us the opportunity to outline briefly some of the services that could contribute to alleviating the pressure on the health service and improving the delivery of health care. My colleagues and I will be pleased to answer any questions members may have.
In the absence of Deputies Billy Kelleher and Caoimhghín Ó Caoláin, whose apologies are noted, as is the presence of Deputy Sandra McLellan, I ask Senator John Crown to contribute first.
Our strange health care pie has many ingredients. As such, I acknowledge the critical role pharmacists have played in keeping a limping service alive for so long. We are all grateful to them for performing that function. In addition, every doctor will have had occasion to be grateful to a pharmacist for spotting a mistake in a prescription and thereby avoiding something bad happening. Pharmacy provides a tremendous back-stop service.
We need to take a radical new look at the way in which health care is delivered. It is not a question of reform but a much more fundamental change, whether a re-engineering or perhaps even a revolution. I am not sure what is the correct way to describe what we need to do to deliver health care in this century.
It is suggested that the role of the pharmacist be expanded from one where he or she often follows directions provided by a doctor for the safe dispensation and prescribing of medicines to one where he or she makes more independent clinical decisions. Will this require a fundamental change in the way in which we educate pharmacists? Will it require a new generation of pharmacists with a fundamentally different skill set from the existing generation or is it possible, with the existing skill set, to adapt work practices in a safe direction? I am not arguing for one option or another as I honestly do not have the answer.
Pharmacy, like the travel, newspaper and music retail industries, is undergoing a fundamental change, driven partly by technology and partly by modern management practice. In the case of pharmacy, an emphasis is being placed on the cost benefits that accrue from having large multiples as opposed to individual retailers. Is this process inevitable and, if so, how will it affect IPU members? What will be lost if the retail landscape of pharmacy changes in this way?
I thank Mr. O'Loughlin for his comprehensive presentation. On the issue of working with patients, the appendix refers to a new medicines service that would involve follow-up for patients who are prescribed new medicines. Is such a service up and running and, if so, how well is it operating and how can it be improved? What is being done to proactively promote this type of change?
On the 12 drugs that could be made available without prescription, will the changes required be introduced shortly or must we wait on regulatory change to take place before this proposal can be implemented?
What progress has been made on dispensing generic drugs? Ireland has traditionally had one of the lowest rates of generic drug use in the European Union. Is progress being made in increasing the rate towards the European average?
Has progress been made in that area to date and what remains to be done?
There was a case in which a person went to seven GPs and got a prescription from each, following which he had his prescription filled by seven pharmacies. Under the system that operates in Denmark, patient medication cards, which look similar to Visa cards, are used. One goes to one's GP but one does not get a prescription on paper; instead, the GP puts the prescription on the card and gives the card back to the patient, who can then use the card to get his or her prescription. The system is about carefully monitoring what drugs people are on. Does the Irish Pharmacy Union consider it has a part to play in promoting that idea in order to give protection to the pharmacist on the one hand, and to provide protection to the card holder on the other? It would help to ensure a patient is not getting one lot of drugs from one pharmacy and another lot from another without each knowing what the other has given out. Have the witnesses discussed with the Department how we can work towards rolling out that system?
I thank the witnesses for appearing before the committee. This is like "Groundhog Day". Not only have we had this conversation in this room previously; we also had it at the Fine Gael committee. What the Irish Pharmacy Union has said today is exactly what it said six and nine months ago. I disagree with Senator John Crown that the service offered is a limping service. That it is such a superb service is the reason we should be rolling out all the other initiatives he has suggested not only today but previously. As a committee, we have had conversations with the HSE and the director who is responsible for this area. The HSE views all the services he has proposed as wonderful and cannot wait to sit down to discuss them with him with a view to putting them in place. What is happening with the negotiations? Has he discussed any of the ten items on his proposed recommendation agenda today? Has he discussed pharmacy fees, given that the representative body has large amounts of money in the bank and does not necessarily need to maintain the fees? Has any move been made on that issue? The last time we spoke, the only two types of professional who could not continue to practise once they had been declared bankrupt were politicians and pharmacists. We have managed to sort out the politicians' side. Is there any real movement on a drafting of an amendment to the Act? What has happened since the last time we discussed this issue? I hope I will not be told that nothing has happened, but please enlighten me.
On a point of clarification, what was it that I said?
I will allow Senator Crown to speak again.
The Senator said the service was a limping service.
The health service is a limping service, not the pharmacy service. I said pharmacy acts as a band-aid on a limping health service.
I thank the witnesses for their presentation. I have a couple of follow-on questions from those raised by Deputy Regina Doherty and Senator Colm Burke. Unfortunately, there has been a huge increase in polydrug use and the abuse of prescription drugs. Given that the street value of benzodiazepines, known as "benzos", is quite high and that it is common for people to be addicted and to abuse such prescribed medications, is there a system in place whereby pharmacies dispensing the medication can talk to each other in case a person gets multiple prescriptions from GPs? I am aware that a report was commissioned by the Department on prescribing patterns. We all have anecdotal evidence of certain parts of the city or the country where benzos are prescribed more often than in others. Perhaps the witnesses would speak about that issue.
In the past couple of years, pharmacists have been able to dispense emergency contraception, known as the morning-after pill, for which there appears to be a huge variance in price, ranging from €9 to €45. The Union of Students in Ireland currently has a lobby on this issue, although it has limited funds. This may link in with the minor ailments scheme. A student or young person in need of the emergency pill cannot get it on her medical card but must go to her doctor for a prescription. For me, that defies the whole logic of being able to walk into a community pharmacy, as there issues that may surround the emergency pill for such young women in terms of stigma. In Portugal emergency contraception is free, in the UK it costs €7, and in Belgium it costs €15. In Ireland there appears to be a huge variation, with prices ranging from €9 to €45 for the emergency contraceptive pill.
A number of questions have been raised. I will not field them all but will invite my colleagues to respond.
I can start with Senator Crown's questions. I acknowledge and thank him for his observation that pharmacy acts as effectively a band-aid on a limping health service. His question was around whether we need to re-engineer pharmacy education and training to provide pharmacists with the skills to take on the new roles being discussed. The education and training of pharmacists in Ireland has actually evolved dramatically in the course of the past decade. It is 20 years since I qualified as a pharmacist. If I were to start in first year in any of the three pharmacy schools in the country now, I would be learning much of this for the first time. The skill set and the knowledge base are in place already. The Irish pharmacy degree and training comply with the relevant EU directive, which means we receive the same training and skill sets as pharmacists in any EU country. In other countries, all of these services are being delivered quite effectively. As our skill set and training is analogous to that in countries such as Canada, Irish pharmacists do not struggle to re-register in Canada.
The Senator referred to pharmacists' moving from following instructions to making independent clinical-type decisions. Every day, pharmacists are making independent decisions, albeit around minor ailments, and referring people to other parts of the health care service and to other health care professionals as appropriate. He also asked about pharmacy business models and how they are changing, the impact of the Internet and pharmacy chains. I invite Mr. Daragh Connolly to respond to that question, as he has done some work in the area.
We think that what Senator Crown is referring to is what one might call mom-and-pop pharmacies. There has been constant change in pharmacy in Ireland since the introduction of the State. Pharmacy is practised in different ways in different jurisdictions, so pharmacies look different in different countries and those pharmacists have different skill sets. Pharmacists not only are good health care professionals but must also be good retailers. Many people are not playing to their strengths because previously they did not have to work so hard at the retail end. There is some agglomeration, with co-operatives of pharmacies coming together in order to give the best value to patients and to be able to give the expert advice those patients want. The service is evolving and ongoing. We live in turbulent times and always look at our overheads and cost models and endeavour to offer the best value we can to patients and customers. We enjoy being embedded in our communities. We enjoy the accessibility we can offer within our pharmacies to patients and customers.
To refer to Senator Ciara Conway's point about emergency hormonal contraception, by being able to keep the doors open and by having a retail offering as well as the expert health care advice, we can be available on Saturdays for emergency hormonal contraception and other facilities that cannot be reached through primary care - that is, GPs.
Senator Colm Burke asked about the new medicine service referred to in the appendix to our document. He also asked about generic drugs and patients attending multiple GPs to get multiple prescriptions for the same medicine and having them filled in different pharmacies. Mr. Bernard Duggan will speak about the new medicine service.
I thank Senator Burke for his question. The new medicine service is currently being implemented across the water in the UK and we are calling for it to be introduced here. We know anecdotally that when we see our patients coming back having been prescribed a new medicine, they need increased support. For example, for certain types of condition for which the new medicine service is available in the UK, such as cardiovascular disease, diabetes and asthma, people are put on long-term medication to control the disease and to prevent it from getting worse and progressing.
In the new medicine service, when patients are initially prescribed medication, they will have an initial consultation with the pharmacist who will outline what the medicine is for, how the patients should take it and what they should do if they experience side effects. This is something we do when we dispense medication, but the difference with the new medicine service is that patients will return to the pharmacy on two separate occasions a number of weeks later when the pharmacist will again sit down with them to assess how they are getting on in taking the new medication.
Typically, we find that patients stop taking their medication in the early stages because they do not have support in taking it. They might, for example, experience a side effect and not know what to do. The new medicine service provides an outlet for them and allows them to sit down again with their pharmacist to discuss how they are getting on. If they are having medication problems because of the new medicine, the pharmacist can address them and either provide them with support to continue taking the medication or refer them back to or make contact with their GP in order to ensure they remain on some medication for their condition.
On the outcome of that service, the experience in England has been that one third of patients who were previously not taking medicine properly go on to take the medicine properly following intervention by the pharmacist. Obviously, some work needs to be done to try to get the other two thirds to take their medicine properly, but even to get one third of non-adhering patients to improve their medicine taking has a benefit.
On the timescale for the moving of medicines from prescription to non-prescription status, the Health Products Regulatory Authority, HPRA, formerly the IMB, will publish a list within the next couple of weeks. There are no legislative changes required because, under legislation the authority already has the role of deciding whether a medicine should be a prescription medicine or a controlled drug and whether, within the prescription medicine status, it should be considered an S1A, non-repeatable, or an S1B, repeatable. The authority as an organisation has taken a policy decision to be more proactive in rescheduling medicines which currently require a prescription to non-prescription status because it believes these medicines to be appropriate and safe for use with the advice and support of the pharmacist, as opposed to needing a prescription.
In regard to generic drugs, we have made rapid progress in the penetration of generic medicines in Ireland since the passing of the Health (Pricing and Supply of Medical Goods) Act last summer. It is now obligatory for pharmacists to offer a generic interchangeable medicine once one is available, when medicines have been deemed interchangeable by the HPRA. We know anecdotally from speaking to the primary care reimbursement service, PCRS, that it has seen the use of generic medicines escalate dramatically. The pharmaceutical industry also tells us that the use of its branded medicines has collapsed where generic alternatives are available.
We also have a process called reference pricing, a rolling process, under way. This is a process by which the HSE sets a reference price - the maximum price it will pay for any generic medicine. These prices are set anywhere between 40% and 70% lower than the price of the products beforehand. Therefore, the combination of the increasing use of generic medicines and the reducing price of generic medicines means that at the lower end of the price scale of medicines, significant savings are coming through. What will drive our medicines bill in the future is not the tablets 95% of patients are taking on a daily basis but the high tech biological type medicines that smaller numbers of patients are taking to treat more serious conditions.
Is there any anecdotal evidence of a change in patients who have switched to generic medicines in terms of side effects or more regular taking of their medicine?
Some patients are uncertain about generic medicines. Also, some research conducted by the University of Limerick two or three months ago suggested some doctors were a little uncertain about such medicines. However, all of the medicines have been assessed, regulated and licensed by the HPRA on the same basis as proprietary branded medicines. When patients are uncertain, it is usually because it looks or tastes different, but pharmacists can reassure them that the tablets have been produced to the same high quality. Once they receive that reassurance from the pharmacist, the majority are comfortable to continue taking them.
On the drug card used in Denmark, in order for something like it to be rolled out in Ireland, we need unique identifiers for patients. For a shared health record of patients, every patient, every health professional and every premises from which health services are delivered must be uniquely identifiable. The Health Identifiers Bill is due to pass shortly and when in place will be the first key step in putting in place the infrastructure required. The question was asked whether we had started talking to anybody about that shared drug record. We have been in discussions with the Department of Health on how it proposes to implement an electronic health records system. As a stakeholder, we have made ourselves available for all of the discussions to be held and the Department has agreed to include us in its stakeholder engagements. We will bring our expertise to bear and what we know from our colleagues around Europe.
Similar to the system operating in Denmark, French pharmacists have a system whereby if a patient slots his or her card into the card reader in the pharmacy, the pharmacist can see not only all of the medicines the patient has been prescribed and which have been dispensed to him or her but also any over the counter medicine the patient has bought because the system allows pharmacists to make a record of non-prescription medicines purchased. This is an essential patient safety measure and I hope we can move towards such a system. We were probably a little slow in putting the basic infrastructure in place, but we will have the unique identifier system soon and the health information Bill will follow. Once these are in place, there is no reason we cannot start working on having such a system. In one way, because we are slow, we can benefit as a result of identifying some of the pitfalls identified in other countries. The NHS has spent billions, if not tens of billions, on a system that probably does not work; therefore, we now know what not to do.
I will not argue with Deputy Doherty. It is a little like "Groundhog Day" and I am aware that many others and I have said similar things previously. We have learned that progress is slow and incremental and that great patience is required to see change. The Minister of State with responsibility for primary care, Deputy Alex White, came to our conference in mid-May and said he was extremely open to the idea of introducing new services through pharmacies. He was particularly anxious to see us come forward and identify the services that could be introduced quickly without legislative change or with the minimum change possible. That is the reason we chose the two I have referred to as a starting point. We intend to return to the Minister of State or to whoever will hold that position to engage on these two services and explain that we can deliver on them now. The minor illness scheme should be cost neutral to the Exchequer because patients are entitled to have these medicines. All we are trying to do is to streamline the process by which they access these medicines.
Has there been much engagement with the IMO on the issue?
There has not been engagement with the IMO as it is not up to it to decide what should happen. However, I have had a conversation with the CEO of the Irish College of General Practitioners, ICGP, who understands exactly what we are saying about the expansion of the role of the pharmacist. We are at pains to point out that we are not talking about usurping the role of doctors or elbowing them out of their traditional role. We are saying that if these were private patients, they would have immediate access to these medicines.
In terms of medicine use reviews and the other expanded services, the experience in other jurisdictions has been that whatever initial trepidation there might have been, when the services are rolled out, doctors and physicians see the benefits. As Senator John Crown pointed out, doctors, physicians and pharmacists work in collaboration and co-operation in the interest of patients. The line between who does what may shift from time to time, but ultimately physicians make the diagnosis and identify the care plan appropriate for the patient. Pharmacists will make decisions within that care plan to achieve the best outcomes for patients.
Therefore, there is complementarity.
There is definite complementarity and no reason for any professional group to feel threatened by the activities of any other. To put it bluntly, as one of the HSE national directors did recently, there is more work to be done than we can do. There is more work available for health care professionals than can be done.
On the question of poly drug use and abuse of prescription medicines, this has been an issue and it is becoming a greater issue for some of our members because people who are addicted to medicines such as benzodiazepines cannot access them.
They cannot get access to them by getting a prescription from doctors because doctors are becoming a little more scrupulous or careful about prescribing these medicines. Our members are being robbed at knifepoint and gunpoint and at the point of baseball bats by people who are desperate for drugs either for themselves or to sell them. We are acutely aware of that. We had engaged previously with the Minister of State with responsibility for primary care before the drafting of the amendment to the Misuse of Drugs Act. We were as keen as she was to do something to help to alleviate this problem. There are prescribing guidelines in place for benzodiazepines and we have published these guidelines on our website. All our members are aware of them and of their responsibilities in this area.
Pharmacists are in contact with and talk to one another. In every community pharmacists get to know the community and that some prescriptions are more genuine than others. They become immediately suspicious of people who go to one doctor for all their treatment and then suddenly appear to go to another doctor for a prescription for a particular item. We talk to each other and lift the telephone all the time. In my area, the western region, the HSE has put in place what is termed a cascade system. If I have suspicions about a prescription, I ring the next pharmacy or two pharmacies on the cascade. They know, in turn, the next two pharmacists to ring and therefore within minutes every pharmacy in the region has been alerted to the fact that some prescriptions are doing the rounds which may not be as authentic as they might appear at first glance.
There was a question about price variations for emergency hormonal contraception, colloquially known as the morning after pill. We do not have a role in pricing. We are scrupulous about ensuring that we do not make the mistake of thinking we have a role in what prices are charged by private pharmacies to private patients. Under competition law it would not be appropriate for us to take a view on that. I accept the point that there is considerable price variation. The first pharmacy to bring that service to market charged €45 at the time. This compared rather well to what it would have cost to go to a general practitioner and secure a prescription. All I can say is that within local markets pharmacies compete with each other to deliver the best value they can. Anyway, we cannot take a position on the price that they charge for competition reasons. I absolutely agree it is ludicrous that a woman who needs access to emergency contraception and who has a medical card should have to choose between getting it on time by paying for it or having to wait to get a prescription so that she can get it later. As we all know, the sooner the medication is taken, the more effective it is and it effectiveness drops off rapidly as time passes. This is a strong argument in favour of the minor ailment scheme that we wish to roll out with a view to improving access to medicines. I hope I have answered everyone's questions.
What is the experience of your members of people who come with a prescription in their hand only to discover that their medical card has been terminated? Have your members had that experience with people? Have people had their medical card terminated without their knowledge? How do your members cope or react in that situation?
To avoid a scenario where a pharmacist would have to refuse to dispense a person's medicines or explain to someone who assumed he would not be paying for his medicines that they are expensive and that he would have to pay for them because his card has come up as invalid we have negotiated a protocol with the primary care reimbursement service. Under the protocol, once a patient has a properly-completed general medical services prescription form from his general practitioner there should be no problem. The GP is the gatekeeper, as it were, to a patient's eligibility. If the GP issues the prescription, then we can dispense the medicines in good faith. The primary care reimbursement service will flag to us afterwards that there is a question mark over a given patient's eligibility or the validity of his medical card. We will then go back to the patient and explain that he needs to contact the HSE because there is an issue with the eligibility or validity but we can dispense the medicines on the day. What we have achieved through this protocol with the PCRS is a scenario whereby no patient should be turned away from a pharmacy without his medicines simply because his medical card has been withdrawn. The idea is that patients have time to make whatever arrangements are necessary. Once we have the properly completed form we can dispense in good faith.
I wish to interject on that point as well. What Mr. O'Loughlin says is absolutely true. Those are the protocols. As the committee will be aware protocols are often difficult to nail down. If someone works in a system and know the protocols they can be perfectly evident. However, there can be considerable distress among patients who may have left the reception because the computer programme used by the doctor cannot generate a medical card prescription and it is written on a private form instead even though there is an old number. Certainly, it is distressing for the constituents represented by the members at this committee and the patients we have. We must work through the process and we gladly work through it with people but it needs to be tightened up because it is creating anxiety. There is one aspect of this which I see on a day-to-day basis in my pharmacy and which I find particularly heartbreaking. It can result in people having to leave employment if they lose their medical card because of the cost of the medicines, at €144 per month. Furthermore, it might highlight to a person that he could be on psychoactive medicines, which can be expensive, and it may show that his condition can take him out of employment. There is considerable anecdotal evidence in this regard.
My question is on the medicines review service. What needs to be done to have that up and running? I am a little unclear about what needs to be done. The deputation made reference to what is happening in Scotland and elsewhere in the United Kingdom. What do we need to do here to put that in place?
Are we taking the questions one at a time, Chairman?
Yes.
It would require the HSE to commission the service. It would require agreement on what the service would look like, to which patients it would apply, what fees would be paid and who would receive the report. It would simply require a discussion or negotiation. We ran a pilot of the programme and we have established that it works. Mr. Duggan was involved in the pilot programme and may wish to comment on it.
We noted in our submission that there is considerable international evidence to show that carrying out medicines use reviews improves compliance and helps people to manage their medicines better. We engaged with the HSE and the Irish College of General Practitioners. We picked several sites throughout the country and rolled out a pilot medicines use review service. Under the service the primary care team and the local community pharmacist came together to identify patients who would be appropriate and who would benefit from a medicines use review. The medicines use review was carried out with the patient and any issues the patient was having with the management of his medications were addressed. These issues were communicated to the patient's GP. It is important for everyone involved in the patient's care to be aware of what is going on in order that we can all work together to improve the patient's care. Then, four to six weeks later, a follow-up medicines use review was carried out to determine whether the patient had benefited from the initial review and whether the medication issues initially addressed in the review had been resolved. Again, that information was shared with the GP. We found that patients were more aware of what the medication was for and how to take it correctly. Furthermore, GPs found it to be a beneficial service in terms of the communication between the community pharmacist and the GP in respect of the overall care of the patient.
Have we had discussions with the HSE at this stage or is it in limbo?
At this time we have not had specific discussions on the service. We have made a sufficient-----
Why is that the case? Is there fault to be attributed or is there some reason for that?
To be fair to the HSE - words I never thought I would say - the executive has it own resource issues. Also, the HSE is working on expert care programmes. The HSE has expert groups working on programmes for specific patient cohorts. I expect that once those groups have reported and then the expert care programmes are in place or published the pharmacist's role will become clearer for medicines use reviews targeted at specific patient groups based on their medical condition.
I thank the deputation for the presentation. One of the greatest assets any community can have is a pharmacist who knows the people on a first name basis. That is important because, as the deputation has explained, pharmacists are able to relate to people better. I welcome the fact that the flu vaccination can be given. I also welcome the fact that pharmacists now participate in the methadone treatment service. That is very important, particularly in parts of the community I represent because people do not have to travel and people in other parts of the country do not have to travel either. That is important.
I wrote to the Irish Pharmacy Union some time back with several complaints from families of older people who have been changed onto generic drugs.
Some did not take them because the box was a different colour and they were frightened. A couple of weeks later the pharmacist asked why they did not take them and they said they did not realise they were the right ones because they were a different colour. They do ask the pharmacist to tell older people it is the same drug but in a different box. That is very helpful.
I have seen older family members who are on repeat prescriptions keeping a store of different concoctions in their press. I have told several doctors in my area to make sure that if people have not used drugs they do not leave them lying around because as well as pharmacies being broken into and attacked by people looking for drugs, houses are broken into and drugs left lying around are taken.
Do pharmacists communicate with people on repeat prescriptions to ask if they have taken all the previous medication? I have seen older members of my family storing up drugs. I am concerned for their safety and in general if they are prescribed drugs that they do not need.
I will start at the end and work back up through the questions. The question of people collecting medicines they do not need, or that they do need but do not take is serious. We have always advocated a dispose of unused medicines properly, DUMP, scheme to get the medicines out of people’s homes. People can clear out their cupboards and bring the medicines back to the pharmacy so that they are not in the house, running the risk of break-ins or of children and grandchildren getting their hands on them. It means too that the pharmacist will see what is not being taken and will know that it is either something that should no longer be dispensed to the patient or will have to tell the patient that he or she must take the tablet because it is quite important.
The incidence of people collecting medicine from the pharmacy that they do not need is falling off because of the prescription charge which is now €2.50 an item. That might not sound like a lot of money but in some people’s budgets it is quite a lot, especially if one is taking ten medicines and it adds up to €25. Pharmacists are reporting now that more patients come in with multiple items on a prescription and say they will only take the sleeping tablet and pain killer now and come back for the others later when they have the money. It is almost like a pay as you go system for filling prescriptions as people eke out their medicines to try to avoid paying the charge until it has to be paid. That will become a bigger issue than unused medicines in people’s houses in future.
I agree that it is important for pharmacists not to just hand out the medicines to people but to say the box, the name, the tablet all look different but it is the same. Many pharmacists now write the old name on the label. For example, for a generic drug such as atorvastatin, which used to be called Lipitor, the pharmacist will write “same as Lipitor” on the label. We do not want patients not to take their medication because they do not recognise the name. Equally, we do not want them taking medication from this month’s yellow box along with some from last month’s blue box, if it is the same tablet, and accidentally doubling up on it.
I thank the witnesses for being here and their members who provide a tremendous service in the community. Those of us who actively engage with constituents recognise that pharmacists are a very good resource in the community. They are very accessible and when the generic referencing started they helped in many ways to calm the waters and provide good information to people, in particular elderly people who were concerned about the different colour boxes. I hope that this afternoon’s meeting will have given them a platform.
The committee might follow up on the proposals regarding the medicines use review with the HSE and we might find out from the Department what stage that legislation on bankruptcy provision is at.
We should start to push the two schemes the witnesses are proposing, particularly the minor ailment scheme which is cost neutral. Very few schemes these days are cost neutral. We will push it with the HSE at our quarterly meeting.
We should have rolled out the new medicine service years ago. It is a very important proposal and should be followed through.
There is merit in those two points. Is it agreed that we follow up on them with the Department and the HSE and regarding the bankruptcy provision and the Pharmacy Act? I thank the witnesses for being here and acknowledge visitors in the gallery.
I remind members that their observations on the end of life care report are due back before tomorrow.
