I welcome the Minister, Deputy Donnelly, to the House.
Health (Miscellaneous Provisions) Bill 2024: Committee and Remaining Stages
Sections 1 to 8, inclusive, agreed to.
SECTION 9
I move amendment No. 1:
In page 11, between lines 17 and 18, to insert the following:
“(I) in subparagraph (ii), after “or class of medicinal products,”, by the insertion of “to include Opioid Substitution Treatments,”,”.
This is much in the same vein as the conversation we had last week, and I note we have not had much time in between to converse on it. To reiterate the points I made on the previous Stage, this amendment would insert an explicit reference in the Bill to the capability of registered nurses to prescribe opioid substitution treatments, OST. Legislation was introduced in 2006 to facilitate nurse prescribing of certain medications, including opiates, in a range of clinical areas, but not for the purpose of drug treatment. Nurse prescribing of OST is a safe and effective mechanism and has the potential to significantly expand access to drug treatment, lifting people out of active and acute drug addiction and saving lives in the process. Nurse prescribing for OST is an established practice in other jurisdictions, including Northern Ireland, Great Britain, the Netherlands, the United States and Australia.
The national drug strategy 2017-2025 commits to improving the availability of OST, also referred to as OAT, by examining potential mechanisms to increase access to the expansion of GP prescribing and nurse-led prescribing and through the provision of OAT in community-based settings and homeless services. Despite this fact, in response to a recent parliamentary question tabled by Deputy Gould, the Minister of State in the Department of Health stated there is currently no objective need for the introduction of nurse prescribing of OST or OAT. Perhaps the Minister in his reply would provide a little more context to understand how this need has been determined.
According to the 2023 Focal Point Ireland report on drug treatment, opioids were the second most common main problem drug reported in 2022 at 33.1% of all cases treated, overtaken by cocaine for the first time. Heroin accounted for 86.6% of these opioid cases. Outpatient OST and OAT for people with problem opioid use is presently provided only through specialised HSE outpatient drug treatment clinics, satellite clinics or specialised general practitioners in the community. Because of this, waiting lists for access to treatment are not at all unusual, particularly in many of our rural communities. Allowing nurses to prescribe OST would cut, and potentially even eliminate, waiting times and ensure a more holistic and rehabilitative response to treatment of addiction.
According to reporting in The Irish Times informed by HSE and Health Research Board, HRB, data, 70 people were waiting to be entered onto the central treatment list for OST in November 2022. From referral to assessment, the average waiting time nationally is 4.9 days. However, this ranges from less than a day in the mid-west to 12.7 days in the south east. After assessment, waiting times for the commencement of treatment outside Dublin can be as long as three months.
In a report in 2022 regarding an examination of the present approach to sanctions for possession of certain amounts of drugs for personal use, the Oireachtas Joint Committee on Justice made two key recommendations relating to OST. The first was for the Department of Health to support the continued expansion of Ireland’s opioid substitution treatment, OST, programme to ensure the treatment is more widely available to communities across the country. The second recommendation was to undertake an evaluation regarding the role that non-medical prescribers could play in treating opioid addiction in Ireland by increasing access to OST. Have any actions have been taken within the Minister's Department to give effect to these recommendations?
According to Dr. Peter Kelly, assistant professor in mental health nursing at Trinity College Dublin, implemented nurse prescribing of OST was recommended for Irish services by Professors Michael Farrell and Joe Barry in the 2010 independent review of the opiate treatment protocol with a view to expanding the availability of OST and in keeping with international best practice. Further, a 2023 review of empirical literature authored by Banka-Cullen identified that this model of prescribing is effective in increasing the numbers in OST treatment, especially for more deprived populations and in rural communities.
While the Minister may not be in a position to accept this amendment today, I urge him and his department officials to take the requisite steps to facilitate nurse prescribing of OST in Ireland as a matter of urgency. On a practical point related to empowering and expanding the role of nurses in respect of prescription of OST, we often look to the waiting lists as the reason that something should be expanded. However, on a practical level, within doctors' surgeries, clinics, community care teams and hostels, it will often be found that nurses are present to a greater degree than doctors, even in the waiting room. Many of the people I support who are on long-time opioid methadone treatment could often be left sitting in a waiting room in their doctor’s surgery for up to two or three hours, waiting to go in to see their doctor to receive what is a weekly prescription for methadone.
Nurses should be empowered in this regard to make the experience a much better one for people instead of leaving them sitting around waiting, when nurses are there, ready and able to prescribe, if the legislation saw fit to allow them do so.
I thank the Senator both for the amendments she tabled and her very considered contribution on what she is trying to achieve. I will not accept the amendments and will explain why. However, I fully agree with her healthcare objective, which is to make sure that people who are in addiction and need opioid substitution treatments can get them in as easy a way as possible. It is interesting that the note I got from the Department indicates it did quite a bit of work in preparation for today. I have been reading through it. The Department notes that there are not significant waiting lists for opioid agonist therapy, OAT. While that is great, as the Senator quite rightly said, people are still waiting several hours in a surgery. Even that is something we need to work on. The good news is the number of GPs is increasing. We currently have 68 GPs who are authorised. The cap on level 2 GPs has been extended this year from 35 to 50 patients. There are more GPs and those GPs can now see more people.
On the care that is needed, one of the matters raised with me by the Department in consultation with healthcare professionals is that in a growing number of cases, there is an ageing population with comorbidities. In many cases, it is important to have a GP involved because a lot more is going on and there is a lot more care. While a nurse may be able to prescribe methadone, he or she will not necessarily be trained to consider patients in their totality. More and more multidisciplinary assessment is required. The issue is one I am very happy to explore. I will just make the point that whatever we do, we have to make sure that the people we are treating and supporting can still get access to multidisciplinary support. Nursing support is phenomenal but may not be enough. We need to think that through very carefully. From a policy perspective, and this is something the Minister of State, Deputy Colm Burke, is very involved in as part of his portfolio, further work on ensuring that those in addiction have the greatest access to the best possible rounded care is something we can definitely work on. I would be very happy to talk to the Senator further about it, especially as she brings knowledge from service users as to what they need, which may not always get picked up here. That would be very useful.
Specifically to the amendment, there are two amendments to section 9. One is around including OST in prescriptions and the second is about urgent lifesaving care. I might come back to the latter, if the Senator wishes to speak to it. I will speak to the first part of it. Essentially, we do not need to include OST. In fact, the legislation as it stands is sufficient for the Minister of the day to include it by secondary legislation. The task force, which I will speak about in the wrap-up if I may, is coming to recommendations. We are starting very deliberately on common conditions and OST is more complex. It is not something the task force is recommending for now but what the Senator is very reasonably trying to do is future-proof the legislation. It is in fact future-proofed. If in the future there were a clinical recommendation to move into more complex areas, and if OST happened to be one of those, that can already be expanded under the Bill, as drafted, through secondary legislation. It would require an amendment to the Misuse of Drugs Act as well. There is more that needs to be done, but what the Senator is seeking to achieve with the amendment is already covered. It would be down to secondary legislation and expert recommendations. We would then need to update the Misuse of Drugs Act.
I will ask the Department to send the Senator a detailed note on nurse prescribing. The advice I have is that such prescribing is covered already. We need to make sure of where it is done. Where people need medical or multidisciplinary care and we are looking at comorbidities, that should also be something provided in the service for them.
On amendment No. 1 and the holistic nature of care, the ageing population, especially in respect of methadone, is a very relevant general point about addiction services. I do not know whether access to capital funding comes under the Department historically but not only is the population ageing, access to appropriate community drug services that people avail of is becoming much more difficult. These are not accessible and do not have lifts. This may not be the case in primary care services, if someone is going directly to a GP. However, we still have community drug teams that provide care, which are finding it increasingly hard to meet the needs of an ageing population when it comes to the building and the infrastructure itself.
As far as I understand it, nurse prescribing would not definitely seek to replace the involvement in its entirety of the GP. There could still be a care plan where a GP links in once a month. An individualised care plan could still be created based on what someone's needs are and that could be done in a holistic sense. It is about everyone being able to support the picture as a whole rather than having nurses entirely replace the role of the GP. They would complement each other as necessary as regards people's individual care plans.
I am happy to continue the efforts outside of this debate.
Amendment put and declared lost.
I move amendment No. 2:
In page 11, line 23, after “ailments,” to insert “or in response to the need for urgent or life-saving medicinal care,”
The amendment relates to ailments and seeks to insert “or in response to the need for urgent or life-saving medicinal care”. We have legislation that was amended in the past to allow for the likes of access to EpiPens. There is legislation that allows for lifesaving treatment in that regard but it does not currently involve access to naloxone. The pharmacist has to be the one who provides naloxone to somebody. An individual cannot run in to try to access naloxone and bring it back out to somebody. A person is not able to go to his or her local pharmacy, say that he or she has a situation whereby his or her son, daughter or partner is an active drug user, and that he or she would like to have naloxone, especially nasal naloxone, which is much easier and more convenient to use. There are appropriate online resources to show how someone can use naloxone. Training should not be a barrier to that. For people who are not aware of nasal naloxone, I suffer from migraines and twice a year I will have to get a very specific nasal pump up the nose. That is what treats the migraine. It is no different from naloxone treatment, which is also a nasal spray. Somebody's health cannot be negatively impacted by giving him or her naloxone, even if it turns out that the person was not actually in an active overdose. No harm will be done if the signs of overdose are read incorrectly.
The amendment seeks to provide that prescription medicine should be provided by a pharmacist or other suitably qualified prescriber in circumstances where there is a need for urgent or lifesaving medical care. At present, the urgent piece is covered if the pharmacist is able to respond in the moment.
The lifesaving piece is being able to have access to that lifesaving drug over the counter or in your home, and that a pharmacist can make that call and give it to you. It is not a dangerous drug and will not harm anyone. Even if you are given five, six or seven doses of naloxone, you are not going to be harmed. It is not something that can have an adverse effect on somebody if they happen to be close to an overdose. This is specific to that piece.
The European Drug Report 2024 shows that Ireland had 322 drug-induced deaths in 2020 and 97 deaths per million people compared with the EU average of 22.5. This statistic places Ireland at the very top of the EU table for drug deaths, with more than four times the average number of fatalities. Opioids, namely, methadone, street or prescribed, and-or heroin were involved in 87% of the deaths recorded. Naloxone is only an antagonist for an opioid. When we think of that 87% and consider that naloxone is an antagonist for opioids, which are causing the most deaths, making it as accessible and freely available as possible could go some way to ensuring some of those deaths do not happen. There will be some cases where someone uses and dies alone with no one there to help. You are never going to be able to bring yourself out of an overdose because, at that stage, you have already slipped off into a state of sleep. However, for those who are not alone, who are found by a loved one, who are on the streets or in an estate or whatever it may be, being able to access naloxone is important.
I know this legislation relates to pharmacists but it is also important in the context of accessing medicines within the prison system. What happens in the prison system is that people are trained in overdose prevention and are trained in responding to an overdose among their peers by the Irish Red Cross and so on. Men in the prisons are communicating to me that what happens when someone overdoses is there is a little fear about alerting the people who need to be alerted. They are worried that, if the person is not in an overdose, they may have drawn attention to something for which someone is going to be punished. Are they going to put on a P19? Are they going to have certain enhancements revoked? Will there be a raid on the wing? People start to then negotiate in a situation where there is a potential need for a lifesaving intervention because they are concerned whether the person is in an overdose and if raising the alarm will bring unwarranted attention. We do not want that ever to happen. We have men in the prison trained in naloxone and could have more such men, and if we had that more freely available, the men have suggested having something like a smash box at the end of the wing so that they themselves could make sure they have brought a person around from an overdose and are not unnecessarily risking life on the off-chance that a person might not be overdosing.
I know that is kind of a side point to the consideration of the role of the pharmacist but it is about the wider point of naloxone not being a prescription-only medication for the individual who uses drugs, whose life might be chaotic and who may not remember to go to a pharmacy to get a top-up of the drug. It should be an over-the-counter medicine and people should be allowed to have it in their homes, shops and wherever else it may be. Allowing pharmacists to make the call in that regard could go a long way towards making it happen.
I thank the Senator. I see three layers to this. The first is the pharmacist using it himself or herself. If someone overdoses on the street, can a pharmacist go out to them and use naloxone? As the Senator said, that is already catered for and we already have provision to allow that to happen, subject to the pharmacist getting the appropriate training. I would certainly be more than happy to engage with the Irish Pharmacy Union, IPU, the professional body, so more pharmacists get that training.
There is a second layer. We saw a tragic case, for example, on O'Connell Street some years ago where somebody went into a pharmacy and said they needed naloxone but could not get it. That is the next level. Could the pharmacist go out and do it? Yes, if they are trained. Could they give it to somebody else to do it? No, but we could provide for that in secondary legislation. It would not require this amendment. The Senator's amendment includes the words "in response to the need for urgent or life-saving medical care". I imagine that would be interpreted as something that is happening in a certain moment as opposed to a preventative measure that may or may not be needed for a future situation.
That brings us to the third piece, which I think is where the Senator's amendment is going. As we discussed last week, I am broadly supportive of the idea. I know the Canadians do it, for example. It is saving a lot of lives and would save lives here. It is a broader policy point rather than a pharmacy prescribing point. As with the Senator's previous amendment, if it were the case that the policy was set and there was an expert recommendation that pharmacists could prescribe naloxone, this Bill, as initiated, already covers the eventuality. It would require an agreed policy position and there is not one. It would also require a statutory instrument and subsequent training.
I believe the Bill already covers the first two layers I have mentioned. The first relates to a situation where somebody is outside on the street and the pharmacist wants to give the naloxone to somebody else. We could cover that under secondary legislation.
I do not think the Senator's amendment would cover the third point but I do think it is a matter we need to continue to explore. I will ask my officials to take a look at it. We would need a comparative review to find out what is happening in the UK and how the Canadian experience is working, etc. If, as the Senator and I think, we will hear back that the risk and costs involved are low and the upside is potentially saving lives in many different situations, it is something we should broadly support. However, the Bill, as initiated, already gives us what we need to do that through secondary legislation.
I am happy to accept the comments and intentions of the Minister to continue to explore policy options going forward. I apologise because I have to leave to attend a meeting of the Joint Committee on Drugs Use that is starting in two minutes.
Amendment, by leave, withdrawn.
Section 9 agreed to.
Sections 10 to 13, inclusive, agreed to.
NEW SECTION
I move amendment No. 3:
In page 17, after line 8, to insert the following:
“Report on the Minor Ailment Scheme
14. Within 12 months of the passing of this Act the Minister shall commission a report on how a pharmacy-based minor ailment scheme can be introduced in Ireland. It shall include details regarding how Irish Medicines Board Act 1995, the Pharmacy Act 2007, Health (Pricing and Supply of Medical Goods) Act 2013 can be amended.”.
The purpose of the proposed amendment as an additional section in the Bill is to call on the Government to introduce, or at least assess the viability of, a minor ailments scheme. A minor ailments scheme is an internationally recognised extended pharmacy service which allows pharmacists to improve public health access, shape further future services and broaden pharmacy roles to deliver patient care and improve health outcomes. At present, private patients who want to access non-prescriptive medicines for ailments such as hay fever, migraines or skin conditions consult local pharmacists on the best options for them and pay for over-the-counter medications. However, medical card patients with the same ailment can only access the same medication if they visit a GP or get a prescription. If the Minister were to introduce a minor ailments scheme, public patients would no longer have to make GP appointments, which would save time for both GPs and patients.
Pharmacy-based minor ailments schemes have been introduced throughout the UK to reduce the burden of minor ailments in high-cost settings, including general practices and emergency departments. Some 24 million consultations take place in Irish general practices each year and more than 1 million consultations take place in out-of-hours co-operatives. Irish GPs received €551 million from the HSE in 2017, which implies a cost of €22.98 per consultation. Independent analysis commissioned by the IPU estimates that the full implementation of a comprehensive minor ailments scheme would save almost 1 million GP consultations per year and free up approximately €22 million worth of valuable GP capacity in an overloaded GP service, the equivalent of almost 100 full-time GPs.
I pointed out previously that more than 500,000 people live within 1 km of a pharmacy and 85% live within 5 km of one. In 2006, the IPU made a submission to the Department of Health and Children on a pharmacy-based minor ailments scheme. In January 2009, the IPU proposed the introduction of a pharmacy-based minor ailments scheme at a meeting of the Oireachtas Joint Committee on Health and Children.
In 2015 the IPU centred its pre-budget submission on a proposal to introduce the minor ailments scheme and the then Minister for Health, Deputy Varadkar, announced the introduction of a pharmacy-based minor ailment pilot scheme at the IPU's conference. In July 2016 the pilot scheme was commenced and ran in 19 pharmacies in four towns, namely, Kells, Roscommon, Macroom and Edenderry, for three months. In 2019, the then Minister for Health, now the Taoiseach, addressed the IPU conference and said they all knew the minor ailments scheme worked and that he was fed up hearing about evaluating it. On 2 May 2021 in a video address to IPU members, the present Minister stated he wished to emphasise the important role community pharmacists play in the wider health service in delivering holistic patient care. He also stated he was committed to further developing the role in the context of health service reform. He said he had listened to and met the IPU when he was in opposition and as Minister and that he firmly believed there was much merit in the initiative and seeking to address this scheme. I am therefore asking him to include it in this legislation. He may not wish to but I would put it in there.
I thank the Senator for her amendment and her contribution. The good news is this is the Bill that creates what we were calling the minor ailments scheme and are now calling common conditions, with those requirements to be set out in secondary legislation. As to the report on how this scheme might work, we will not need the amendment the Senator has tabled because this is the enabling legislation.
There are a few things happening. One is the expert group is finalising its work. It will be making recommendations which we will need to consider and implement whichever ones are accepted. In parallel, my Department is talking to the Irish Pharmacy Union about the practicalities of implementing this in community-based pharmacies. The IPU of course wants to negotiate this on behalf of its members. The Senator makes an excellent point, which probably is not widely known about medical card holders. It is pretty straightforward for people who do not have medical cards. At present if they go into a pharmacy because they have, say, conjunctivitis, which just requires simple eye drops, then even though the pharmacist knows it is conjunctivitis they cannot provide the medication because it is under prescription. Today the pharmacist would have to tell the person they cannot give it to them and that they will have to go to the doctor. The person might have to wait a week to see the doctor. I hope this is the case less and less, but in some parts of the country, a person might have to wait and pay €65. The doctor will give the person a piece of paper so he or she can go back to the pharmacist and be given what the pharmacist already knew the person needed. This will allow that to happen. This will allow the pharmacist to basically say he or she has the appropriate training, this is one of the conditions covered and provide the eye drops. It saves time, saves GP time and further enhances the role of pharmacy.
The Senator makes a really interesting point around medical card holders, because what is not commonly understood is even to get over-the-counter medication from a pharmacy, they have to go to the GP, whereas a non-medical card holder may just go in and just pay it. A medical card holder can do that as well, but if they do not want to pay, which they do not have to, then they must ask the GP to write them a note. It is not even a prescription because it is for a non-prescription medicine. They need to take up the GP's time and their own so they can go to the pharmacy for their over-the-counter medicine, which is being sold to person standing beside them for €15. Meanwhile, the medical card holder has had to incur all this healthcare cost and take up their own time and everybody else's time. The Senator makes a really important point about the benefits here. It is a benefit to the individual going in with a rash, conjunctivitis or whatever it is, but there are also going to be other benefits in time. It is not all covered under this, but it is about the policy direction and where we are moving. Medical card holders will not have to waste their time and the GP's time to get something from the pharmacist.
It has probably been a control mechanism in place to date. The pharmacists can play that role. They of course will want to negotiate a fee for playing that role and that is an ongoing discussion with the IPU. I thank the Senator. She has raised some really important points. I am satisfied what is called for here is in fact exactly what we are enabling through the Bill.
I thank the Minister for his plan to allow pharmacists to prescribe. I have worked with many pharmacists down through the years and it is something that will really alleviate the wait for a doctor. Sometimes people have to wait two or three weeks for an appointment with the doctor. Pharmacists being able to prescribe medicines like the conjunctivitis treatment the Minister mentioned is going to help. From speaking to pharmacists and the IPU, they are very much onboard with the whole idea and look forward to working with him into the future on it.
Amendment, by leave, withdrawn.
Title agreed to.
Bill reported without amendment.
When is it proposed to take Report Stage?
Now.
Is that agreed? Agreed.
Bill received for final consideration.
When is it proposed to take Fifth Stage?
Now.
Is that agreed? Agreed.
Question proposed: "That the Bill do now pass."
Some Senators and the Minister wish to speak briefly.
I thank the Acting Chairperson. I welcome that the rent-a-room scheme is included in this Bill. I was not here when we had the discussion about it. I first raised it in September 2022 as a Commencement matter. The Minister of State, Deputy Butler, took the matter on the Minister's behalf and relayed that he said a review was required. The Minister went ahead and had that review. The Department of Education was encouraging people to avail of the scheme to rent out rooms to students, but people's fear of losing their medical cards was the biggest issue. I compliment the Minister, his Department and staff on that because it is a really positive move. There are three third-level institutions where I come from, but such a shortage of accommodation. I have had so many inquiries even between September 2022 and now about when this is going to happen. It is not only a good day for the students, who will now be able to rent a room from people, but also for older people as well. Many people live on their own. Many widows and widowers were willing to rent out their room, but for the fear of losing their medical card. That the fear has now been alleviated is very positive. I thank the Minister, because it is a good news day for all involved.
I commend the Minister as well. This minor ailments scheme, which is now to be called common conditions, is something I have been talking about since I entered the Seanad. It is a game-changer when it comes to community healthcare. I commend the Minister on pushing this forward.
I thank colleagues for their support in passing the Bill. As they have said, it does a number of important things. It provides an income disregard of €14,000 from medical assessment for anyone who wants to use the rent-a-room scheme so that should increase, maybe in a modest way, the provision of those who want to rent out their rooms, which we all know will help.
The Bill also makes it easier for medicine substitution.
It will give end-to-end oversight of where there are blockages and shortages, which is something we currently do not have. It will allow pharmacists, under regulations and protocols, to substitute medicines when we have a shortage. Global supply chains are tightening so this will be used more and more into the future. It broadens and clarifies those who can vaccinate. We did this during Covid. It gives clarity to all of that, which will help as well. As we have been discussing, the Bill, in terms of the future role of pharmacists in our country, is a pivotal moment. The Government has been pursuing a policy of enhanced community pharmacy. We already have powers that allow certain prescriptions to be extended and pharmacists can become involved in more complex prescription, under multidisciplinary teams. This will allow them to prescribe for common conditions and it is the beginning of a new role for pharmacists in Ireland. I have always been of the view that pharmacists who are incredibly highly trained, dedicated healthcare professionals, want to and can do a lot more than they are allowed to do at present. For community pharmacists in particular, this is the law that many of them have been waiting for to allow them to get on with this. For the public, it will mean that people can get access to superb healthcare closer to home, in their village, town or city. For the GPs, it means there will be a shift of some of the work, which is very important for people to be able to access GP services more and more regularly.
I want to thank some people. I thank community pharmacists and the Irish Pharmacy Union, IPU, for their work. We have had a really constructive engagement with community pharmacists and their representative body. The regulator has been fantastic as well. I also want to thank the task force chaired by Professor Pat O'Mahony. He has done a phenomenal job. The task force has been fantastic. I met him today at the final meeting of the task force. The energy, purpose and determination in the room to expand the role of pharmacy was infectious and fantastic to see. It has done in a matter of months things that take years in other parts of the service. I thank the task force for pushing the speed of this project. I also thank my officials in the Department and their HSE counterparts, who have worked really hard on this. It has come across as quite simple legislation today but, in fact, there is a lot of complexity, clinical oversight, protocols and expertise has been brought in. I thank everyone involved. This is a statement of intent from the Government regarding the future role of pharmacy, giving it a bigger role and more access for the public to expert healthcare professionals, closer to home.
I thank the Minister. Sometimes when a Bill has "Miscellaneous Provisions" in the Title we tend to think it is not as important as it is, but in fact, there is a lot of really good stuff in this. No one thanks the Minister so we will thank you.
Sorry, Chair, I thanked the Minister.
You did indeed, Senator
Question put and agreed to.
When is it proposed to sit again?
Tomorrow morning at 10.30 a.m.
Is that agreed? Agreed.
Cuireadh an Seanad ar athló ar 7.14 p.m. go dtí 10.30 a.m. Dé Céadaoin, an 10 Iúil 2024.
The Seanad adjourned at 7.14 p.m. until 10.30 a.m. on Wednesday, 10 July 2024.