Dáil Éireann díospóireacht -
Tuesday, 27 Sep 2016

Vol. 922 No. 1

Pharmacy Fees: Motion [Private Members]

Deputy Dara Calleary

I move:

That Dáil Éireann:

notes:

- the recent €12 million payment made to the Health Service Executive (HSE) in settlement of a dispute over incorrectly claimed pharmacy fees;

- the failure of the HSE to notice irregularities in the pharmacy fees it was being charged by a leading chain;

- the fact that other pharmacies are now being pursued for similar practices; and

- that these developments only came to light following media investigations;

agrees that:

- the fact that a leading pharmacy chain could over claim to such an extent is a serious indictment of the HSE’s monitoring systems;

- there are grave concerns about how many other pharmacies may have been operating similar practices;

- it is incumbent on the HSE to ensure that it is carrying out proper checks and balances when dealing with taxpayers’ money;

- urgent action must be taken to recruit auditors; and

- €12 million could have a major impact in funding other areas of the health service where there is significant unmet demand; and

calls on the Minister for Health to:

- outline what action the HSE is taking to investigate this issue;

- ensure that the HSE conclude its investigations without delay;

- detail how those accountable will be held responsible;

- guarantee that more robust procedures are put in place to restore confidence in the system;

- prioritise the proper expenditure of taxpayers’ money; and

- put in place proper auditing systems.

I congratulate the RTE investigations unit on its work in this regard. The unit has done some outstanding work in recent times and it is a shining advertisement of what public service broadcasting can be. I also pay tribute to the whistleblower within the LloydsPharmacy group who showed significant courage in shining a light on this sorry mess.

The Minister will surely agree the HSE has serious questions to answer for failing to notice irregularities in the pharmacy fees it was being charged by a leading chain. I emphasise the word "chain" as it seems that the problem centres on pharmacy chains rather than the important, independent community pharmacies throughout the country that are struggling to keep their doors open. This sorry episode has undermined them and their work and that should not have been allowed happen. However, the fact that a leading pharmacy chain could over-claim to the tune of £12 million without anyone noticing is a damning indictment of the HSE's monitoring systems. The HSE needs to outline what action it is taking to get to the bottom of this issue. I look forward to the Minister outlining to the Dáil this evening exactly what the response has been.

This is taxpayers’ money going into a service that is under enormous financial pressure. It is incumbent on the HSE - and the Minister - to ensure that the proper checks and balances are carried out when dealing with taxpayers’ money, not just for pharmacies but also in terms of agency fees and for any service involving a third party. When one sees what has occurred in the pharmacy sector, it does not give one much confidence about how the HSE manages its other debtors. Now that a number of investigations are under way, I would like the Minister to be specific in detailing the progress made in respect of them. I also ask him to outline the checks that are now in place to ensure there will be no recurrence of what happened in this instance.

The waste of public money cannot be tolerated. The amount is not negligible. A total of €12 million in the health service could mean 600,000 home help hours. There are currently no home help hours available for any case, including palliative care, in County Mayo. The existing waiting list will subsume all of the extra resources - if they become available - that the Minister allocated during the year. Families are under the most dreadful stress and pressure at present and €12 million would go a long way to alleviate the problem around the country. The sum of €12 million would provide 500,000 additional personal assistant hours for people with disabilities. It would enable the recruitment of some 350 nurses, speech and language therapists or occupational therapists. It would provide 12,000 medical cards. There has been a tightening in the allocation of discretionary medical cards in recent weeks and months. Such money would provide 1,500 home-care packages, which are essential to alleviate the crisis in hospitals. It would fund a network of community neuro-rehabilitation teams four times over or employ armies of hospital consultants. That is what €12 million would do yet the HSE did not seem to notice it was missing.

One should also bear in mind that the HSE was initially warned about the possibility of such a situation arising in 2012 and 2013. That is apparent from documents to which the RTE investigations unit had access. That was at the high point of the very dangerous budgets being introduced by the then Minister for Health, now Senator James Reilly - a time when 30,000 discretionary medical cards were being taken away and when there was a €113 million probity drive in respect of medical cards.

In 2012, senior HSE managers were told that pharmacy fees were open to abuse and misunderstanding but no action seems to have been taken. The Sunday Business Post also did some work in this area and in 2015 it showed that HSE managers were concerned about phased payments, which are at the centre of the dispute. A unit in the HSE identified phased dispensing as a payment risk in 2012. At the time, the unit proposed that rules relating to phased dispensing should be clarified. HSE managers drew up circulars to advise GPs and pharmacists how to operate and claim appropriately for medicines that were dispensed on a phased basis. However, it appears those circulars were never sent. I would like to know why.

The difficulties concerning phased dispensing have been identified and the irregularities centre in particular in this case on the LloydsPharmacy group and on the weekly medication management system known as My Med, which is the modern day equivalent of the old pill box, segregating drugs into weekly packs for those on large doses of medication. The RTE investigations unit, using documentation supplied to it by the whistleblower, shows that LloydsPharmacy staff were actively encouraged to widely promote the My Med system to its customers but additional paperwork supplied by the RTE investigations unit showed that My Med generated substantial additional profits for the LloydsPharmacy group. Branch managers in the LloydsPharmacy chain were advised in an internal memo that they could boost their fee income by almost two thirds by using a system developed within the company. It is important to note that LloydsPharmacy has rejected any suggestion of fraud in its practice of claiming up to four fees in a month in respect of a single prescription. However, its settlement with the HSE to the tune of €12 million must reflect some admission of wrongdoing on its part.

I query the figure of €12 million. Was it a settlement figure or was it the actual amount of money owed to the HSE? Was the figure arrived at following negotiations between the HSE and the LloydsPharmacy group? I would appreciate if we could have clarification on the matter this evening. The opening up of the argument provokes a number of questions which I would like the Minister to answer this evening. The first is to outline the response of the HSE to the specific issue under discussion and, second, to indicate the new checks that are in place. Is the figure of €12 million that has been agreed with LloydsPharmacy a settlement or the specific amount that is outstanding? How many more pharmacy groups or individual pharmacies are being investigated by the HSE? How much money is understood to be at issue at this time?

Does the Minister believe appropriate checks are in place for all supplier relationships with the HSE? Is the Minister confident that agency fees charged to hospitals, hospital groups and various other elements of the HSE are routinely and correctly monitored? Is he satisfied that GP fees are routinely and correctly monitored? Is he happy that the fees paid for those who hold medical cards are routinely and correctly monitored? How many auditors are currently working within the HSE to manage the system of payments which relates to so many contractors throughout the country? Is the Minister happy that the level of internal audit within the HSE is appropriate for the amount of customers it handles?

This is a public expenditure issue as well as a health issue. I have outlined what €12 million could be used to provide in the health service. The health service is facing a huge crisis for the want of money. However, when we look at the money that is invested in it, which seems to be unchecked, it is enormously frustrating for those of us who are fighting every day for resources for constituents and for people who want to use the service.

There is a crisis with regard to home-help services. We also have a crisis in emergency departments and in terms of waiting lists. Those areas could all do with an additional €12 million. The sum of €12 million would have gone a long way to reduce the stress felt by the many thousands who lost medical cards in 2013 and 2014 and had to endure the stress of applying for their cards and then reapplying for them.

The HSE response, as outlined, has been weak. It must be seen to take the issue seriously and show there is an audit chain in place for all of its payments in order that we can have confidence in its ability to manage its own internal finances and customer relationships with contractors. It is unfortunate that a chain would bring this damage down on the pharmacy profession, which does excellent work and is, in fact, under-utilised in terms of its members’ skills and ability as primary care providers. Again, I say that this should not reflect on the integrity of community pharmacies around the country which are struggling to keep their doors open. Once again, big business is damaging not just small operators but also the internal conditions relating to the health budget.

Let this be a warning that we cannot depend on the RTE investigations unit to do the work of the HSE's internal audit division or the Comptroller and Auditor General. We need to know why it took the RTE investigations unit to do the courageous work of highlighting this issue and we need to know from the Minister that work is under way within his Department to stop this happening in any other section of the HSE budget. I would appreciate if he could give an assurance to the House this evening that he has checks and balances in place already regarding all the supplier relationships within the HSE and the management of those contracts.

Deputy Billy Kelleher

I support this motion which I come at from a couple of perspectives. In tabling this motion, we are trying to send out a very strong message to the HSE that it has an obligation and a duty to ensure that it has proper auditing systems in place and that it is fully accountable both to the Committee of Public Accounts, through the Comptroller and Auditor General, and to this House generally, to ensure that there is confidence in it and that the public sees that there is not wastage, particularly in difficult times, when there are huge challenges across the broader health budget in the provision of care and when budget after budget over the last five to six years cut back services and pared supports for the people who most need them. To read about this case of €12 million being overcharged by LloydsPharmacy and a settlement of this magnitude undermines the confidence of the public in the HSE to be on top of its brief in ensuring that there is full accountability and proper auditing in place.

One or two issues have arisen on which I would like a bit of clarity and they have all been referred to by Deputy Calleary. In regard to the €12 million, is that a settlement figure that was offered by Lloyds and arrived at through negotiation or was that after a full trawl of Lloyds pharmacies and their interaction with the HSE regarding the MyMed dispensing and pillbox system that was in place? The reason I ask that is that organisations across this country, which provide wonderful services daily in the area of physical and intellectual disability, are consistently audited, are having their block grant cut on a continual basis and are finding it increasingly difficult to fund their services to the extent that we now have fund-raising efforts across the country by large organisations just to try to provide basic health care for very vulnerable people. It sticks in the craw to a certain extent when they see these kinds of figures, such as an overcharge of €12 million, coming out. It is equally important to find out whether this was a settlement figure offered by Lloyds or whether it followed a full and detailed analysis and audit of all dispensing fees charged by Lloyds over the last number of years.

What is also important is the fact that a whistleblower came forward. That is healthy in the sense that there are now people out there who see that they can, with a certain element of confidence, come forward when they see wrongdoing taking place or when they have suspicions that it is taking place. In this case, it was important that this whistleblower came forward. The difficulty in all of this was that it was the "RTE Investigates" programme which really brought this to a head, even though the HSE had suspicions and it had been brought to the attention of senior management in the HSE that there were potential problems with the dispensing fees and how they were being charged to the HSE.

It is important that I read a circular from Lloyds itself, a notice from its head office to its pharmacies, entitled MyMed Profitability. The notice read "Wondering why we're obsessed with MyMedding?!" and included a graphic which stated "Should show you why it's so important to hit your target. And why it's even better to hit your target early so you can make a real dent on your overall profitability for the year." It goes on to explain how to manipulate, in a way, the MyMed charging system that was in place, whereby normally there would be a €5 dispensing fee per prescription item. When they phased it and put it into the pillbox, they were able to charge multiples of that.

It is very important that we put on the record that we are not disparaging every pharmacist and community pharmacist out there. That is critically important and has already been referenced by Deputy Calleary and others. Pharmacists do wonderful work daily. We all know that many of them are struggling at present in the economic downturn. They provide a very valuable service in communities and villages across this country. I have consistently raised the need for pharmacists to play a more meaningful role in interacting with the primary care system that we are trying to develop. They should be given a much greater role than they have at present. Sometimes when I say that I draw the wrath of general practitioners and others on me but we have wonderful highly qualified personnel in almost every town and village across the country. They should be used in a very effective way in primary care and in alleviating the burden on GP services and systems that are also overburdened at present.

The broader issue is that of accountability in respect of public funds. The HSE and any other arm of the State cannot be seen as some form of cash cow that can be milked regularly by any individual or by an organisation. In that context, the HSE must do a full evaluation of its internal auditing systems because they have been found wanting on numerous occasions in dealing with some organisations, particularly section 38 and 39 agencies, as was instanced at the Committee of Public Accounts previously. They need to be robustly assessed as to whether they have the capabilities and the wherewithal at present or whether they need further assistance and support in terms of personnel and finances to ensure that the amount of money being dispensed by the HSE on contracts and services represents full value for money and that the taxpayer is getting full value for money. In the context of the taxpayer getting value for money, we have been, as I said, diverting funds from the most vulnerable in budget after budget over the last six, seven or eight years. It rests very uneasily with people when they see this type and scale of overcharge, wittingly or otherwise. It is important that all these issues be clarified in the context and the course of the debate.

However, the broader issue, as I said, is that we must ensure that this cannot happen and that there is a further assessment of the internal capability of the HSE to perform its duties in ensuring that it is not only purchasing a service but also getting value for money for the taxpayer and for the people who depend on the HSE itself. Over the next number of weeks, we will be engaging as a political party with the broader issue of budgets for the HSE and the health services across the board. Again, it would undermine our confidence if we believed that this was just a settlement, that the matter was swept under the carpet and that there was no due diligence done on the capacity of the HSE to observe and assess the number of contracts in the pharmacy area and the broader provision of services. When one looks at the overall budget of the HSE, there are huge agency staff numbers and short-term contracts coming into being. It purchases many services from the State that it would have to ensure that it has that capability. The reason I say that is because this did not come as a surprise in view of the fact that the HSE was warned as far back as 2013 that there were issues around the dispensing fee and how it was being broken down and the pillboxing system that was being used by Lloyds in multiplying out a prescription fee fivefold and, in some cases, by more.

This motion is important in that context to bring a bit of clarity from the Minister on what actions he is taking, what actions the Department of Health and the HSE are taking and whether there is a requirement by somebody to refer this to other authorities. That is something that should also be looked at. We must send out a very strong, clear message that public funds must be used in the manner that they were voted for in the Dáil and dispensed or paid out by the HSE. If there is a requirement to do that, then it should be done. I concur with everything said by my colleague and I hope that certain issues that have been raised will be addressed by the Minister.

I hope the Minister will answer the questions that have been raised.

Minister for Health (Deputy Simon Harris)

I thank the Deputies for tabling the motion on what is a very serious issue. The issue before us highlights the challenges the HSE and all public bodies face in the procurement of services from private contractors and the importance of investing in probity and control functions to protect the taxpayer and service users. I echo the comments of Deputies Dara Calleary and Billy Kelleher on the work of community pharmacies. I know where their motion is directed. I also agree with Deputy Billy Kelleher on the expansion of the role of community pharmacists. The issues outlined by the Deputies are deplorable and unacceptable, as I am sure Deputies on all sides agree. The question is what will we do to ensure we get to the bottom of the matter and minimise the chances of it happening again.

While Deputies are right to challenge and question the systems in place within the HSE - that is their job and mine as Minister for Health - we must ensure moneys are spent appropriately. I will address these issues. We must also be cognisant of the obligation on private contractors to comply with the terms of their contracts with the State. Clearly, that did not happen in this case.

The HSE's primary care reimbursement service, PCRS, pays primary care contractors, including GPs, dentists and pharmacies, for goods and services supplied to eligible public patients under community health schemes such as the medical card, long-term illness, high-tech and drugs payments schemes. This is an enormous undertaking. There are approximately 7,700 contracts, with annual payments of more than €2.5 billion. Under the drug schemes alone, pharmacies make claims and are reimbursed for over 74 million separate items every year, or almost 1.5 million items every week. Pharmacists are reimbursed for medicines dispensed to patients in previous months, with a mix of electronic and paper claims. In 2015 the PCRS reimbursed €1.9 billion under the community drugs schemes to cover the cost of medicines and pharmacy fees. This included €1.38 billion in drug costs, including €116 million in wholesale mark-ups and €390 million in pharmacy fees. That sets the scale of the operation. This colossal level of activity is engaged in to a very high level by a single agency. I have visited the PCRS and seen at first hand the hard work, dedication and enthusiasm of the staff who undertake this volume of work on behalf of patients.

The matter raised involves a commercial contractor claiming fees for phased dispensing to medical card patients in community pharmacies. Phased dispensing was established in 1996 for patient safety reasons under the new pharmacy contract. It is a clinical process to help certain patients to manage their medicines. It may be specified by their doctor; they may be starting a new medicines regime or using medicines that are unsuitable for monthly dispensing or, in exceptional circumstances, they may be unable to safely manage their medicines. That is the sole purpose of the scheme. A key part of the process is that medicines are dispensed at regular intervals, for example, once a week, in order that both patient and medicines are monitored. Where phased dispensing is appropriate, pharmacies are paid per dispensing for their professional services.

While the Government is not opposing the motion because of the seriousness of the issue, a number of points need to be appreciated. They concern the instigation, operation and success of the PCRS investigation in this case.

I have been briefed in detail by the HSE about this matter. I understand an HSE data review of phased dispensing in 2014 raised concerns about activity and claiming levels. In early 2015, based on this analysis, the HSE began investigating claiming by Lloyds Pharmacy group. The investigation involved complex analysis of activity for the period from 2010 to 2015 and detailed pharmacy inspections. Such a forensic approach is the only concrete way to establish mis-claiming under current systems. Of course, it was supported by information provided in confidence later in 2015 from former employees and media sources. I acknowledge the role both played.

I am further informed that the investigation was completed in August 2015 and that disciplinary proceedings were being prepared against individual pharmacies within the group under clause 15 of the pharmacy contract. This process can lead to termination of a contract. Following protracted negotiations, Lloyds agreed to a settlement that included full repayment of over-claimed fees. The PCRS continues to monitor phased claiming by the Lloyds group, with further payments suspended until compliance with phased dispensing rules is fully established. The HSE considers that this was the best possible outcome in this case, with full return of moneys owed to the taxpayer. The PCRS is also examining other claiming issues and conducting investigations into claiming by a number of other contractors.

The HSE has advised that, during the Lloyds investigation, it sought advice from the Garda Bureau of Fraud Investigation and the Pharmaceutical Society of Ireland which regulates pharmacists and pharmacies in Ireland. The HSE will make any appropriate referral required concerning investigations. That may well still happen.

The Lloyds fees investigation was a successful operation, set in motion by an HSE PCRS audit of business activity and one that reached a positive conclusion - the full return of all moneys owed to the taxpayer. I agree fully with the Deputies that it was a most serious matter. However, irregularities were detected by, and the investigation was initiated on foot of, the HSE’s own reviews, although also helpfully supplemented by media reports and a whistleblower.

In all payment structures there must be a significant element of trust between contractor and payer. A well functioning probity and control function underlines this and protects the taxpayer, patients and legitimate operators who make up the majority of contractors. In a health setting it also helps to ensure resources go to the people who need them and that maximum value for money is achieved. The purpose of the PCRS audit and probity role is to ensure payments are claimed for services provided. Reviews such as these, in particular pharmacy inspections, are detailed, forensic and time and resource intensive.

Following analysis and restructuring, the PCRS audit function has been, and continues to be, strengthened with the development of dedicated resources. This is a message to the House that we need to do more in this area. That is why we are beefing up the audit function within the PCRS. This objective has been pursued as a matter of urgency and includes the appointment of a head of schemes control, supported by specialist staff, a control steering group and a probity and governance group.

I am pleased to note that the PCRS has, this year, appointed four full-time pharmacy inspectors, two data analysts and two dedicated case managers. A third data analyst and two more case managers are being recruited. This will strengthen the ability of the PCRS to carry out investigations, follow the audit trail and improve its audit function further.

The PCRS probity and control function is also developing a work programme with specific measures for community pharmacy, dental, optical and general practice to ensure claims comply with relevant schemes. The PCRS probity programme is on target to recover €20 million this year as a result of its operations. I am confident that this increased level of activity will set the tone for proper engagement by contractors in providing services for patients.

The House will note the proposed amendment to the Fianna Fáil motion tabled by Deputy Louise O'Reilly on two other issues: reclassifying medicines to over the counter; and transparency in pharmacy prices and services. While I am in a position to accept the Fianna Fáil motion, I cannot accept the proposed amendment. These issues are the responsibility of the relevant statutory authorities, the Health Products Regulatory Authority, HPRA, for medicine classification and the Pharmaceutical Society of Ireland, PSI, for professional practice and conduct.

In general, a medicine supplier applies for a change in status for its product. I understand the HPRA actively seeks applications from suppliers and gives ongoing consideration to the issues surrounding this matter, in Ireland and elsewhere.

The PSI deals with patient queries on pharmacy medicine pricing. Patients are entitled to ask for a breakdown of their medicine costs and the person in charge of the pharmacy should provide that information. The PSI has advised pharmacies that this should include an itemised receipt.

While I accept the principles involved in the amendment, I oppose the amendment on the basis that the issues are matters for the relevant statutory authorities. I do not propose to intervene in their roles at this stage.

I thank the Deputies for tabling the motion and look forward to the rest of the debate. The motion raises very serious and important issues on how we expend taxpayers' money and how we ensure resources this House votes to expend on health services get to citizens and are not in any way misused or fraudulently obtained. I am pleased with the outcome of the HSE PCRS audit, which has recovered every cent of the money owed arising from claims wrongly made by Lloyds Pharmacy Group. I look forward to seeing the beefed-up audit function within the PCRS operating with the additional staff I outlined to the House.

Deputy Louise O'Reilly

I move amendment No. 1:

To delete all words after "unmet demand; and" and substitute the following:

"recognises that the switching of medications from a prescription to a non-prescription basis could reduce the expenditure on dispensing fees; and

call on the Minister for Health to:

- outline what action the HSE is taking to investigate this issue;

- ensure the HSE will conclude its investigations without delay;

- detail how those accountable will be held responsible;

- guarantee that more robust procedures will be put in place to restore confidence in the system;

- prioritise the proper expenditure of taxpayers' money;

- put in place proper auditing systems;

- reclassify those prescription-only medicines identified by the Health Products Regulatory Authority to over-the-counter in pharmacy status; and

- introduce legislation to oblige pharmcacies to inform patients of a pharmacist's dispensing fees, pharmacy services and mark-ups through in-store displays in order that pharmacists would be required to use a standard, clearly, visible template and provide the patient or the patient's representative with an itemised receipt following the dispensing of medicines."

I will be sharing time with Deputy Caoimhghín Ó Caoláin.

I welcome the Minister's confirmation of a full recovery and not a settlement amount. Notwithstanding the Minister's position this evening, I do not believe there is anything that precludes the Government or other Deputies supporting the Sinn Féin amendment.

It is unfortunate that we are discussing wastage in the system, abuse of procedures and, ultimately, a cost to the taxpayer. I recognise and welcome that the full amount has been recouped. I also note that investigations are ongoing. The fact that this motion has been tabled points to a culture that has been allowed to grow and needs to be addressed. We need a plan to prevent it. We need to ensure that there are not other similar incidents or other moneys lost in this way into the future. In that regard, I welcome the measures outlined by the Minister.

Unfortunately, this is not the first time that a large multiple has been caught apparently taking advantage of the rules. In Britain, the same multiple investigated by the RTE investigations unit took advantage of a loophole in the NHS rules which allows pharmacies to bill the taxpayer for whatever a product might cost at the time. Dozens of Lloyds pharmacies dispensed packs of tablets that cost £89 instead of those which would have cost only £3. Following other investigations, the British media disclosed that drug companies were apparently colluding with pharmacists to over-charge the NHS by millions of pounds for a group of drugs known as "specials". This led to the grave concern that the NHS system was not being properly policed. We are calling on the Minister to provide an assurance that the system here will be properly and robustly monitored. It is safe to say that Irish people are sick of one might call "creative compliance", the effect of which we have seen on our banking sector and public services. We need to ensure that public services act in the public interest at all times. This means ensuring that third parties cannot abuse the system. Rather than relying on people to do the decent or the right thing, we need to put in place the mechanisms to ensure they do so.

I understand and appreciate that pharmacists are health care professionals and they are trained to work and care for their patients but conversely they are running a business. In June last year, Lloyds pharmacy announced a price reduction on a range of its prescription medicines. This led to other chains following suit. At that time, Lloyds stated that this could deliver €300 savings per annum on some prescription items. This was, according to Lloyds, part of an attempt to be competitive in the Irish market. At the time, some small community pharmacies were concerned that this could put them under significant pressure, particularly those that would have had large debts, of which we know there are plenty in communities for a whole range of reasons. There was undoubtedly pressure on them.

It is interesting to note that at the same time Lloyds was publicising the delivery of savings for consumers and patients, it was engaged in the process we are discussing this evening. Indeed, its push to be competitive in the market, which may have put pressure on smaller pharmacies, came at the cost of defrauding the HSE of moneys. There was no transparency and no oversight. It was thanks to a whistleblower that this issue came to light. Tributes need to be paid not only to the people in RTE but to those who were brave enough to come forward. It would be interesting to know - hopefully the investigations under way will shed more light on this - if phased dispensing increases revenue and if it is widespread among other pharmacies. I know that it is often recommended by doctors but, unfortunately, Lloyds appears to have been using it as a mechanism to make money and increase its revenue. As I understand it, it is a practice Lloyds encouraged in its pharmacies. I do not believe that phased dispensing, for all its benefits, can and should be used for profit. I think we can all agree on that. The fact is that not only were these chains distorting the dispensing system, they were doing it with flagrant disregard for our health service, the HSE and patients. They did so with such vigour they created targets and goals. It was not an accident, an oversight or a mistake: it was deliberate manipulation of the rules and procedures to maximise revenue for a large and profitable company.

We do not yet know in how many companies or chains this practice was rampant. We do not know if this was isolated to the large multiples, or if in an effort to stay competitive with these companies, other pharmacies were forced to follow suit. We cannot know that. I am not sure we will ever find out. It is not hard to imagine the money that would be required to do a root and branch investigation into how the system may have been abused. It would be naive to think that this might happen because the scale of the task would be massive. The fact is the practice was rampant. We now need to ensure it is stamped out and cannot happen again. In that regard, we must ask what the outcome will be of the investigations. Those who have been found to have overcharged through an abuse of the system will reimburse the moneys but how will the culture and the practice change? Will there be a new code of practice and, if so, how will it be negotiated and how will we ensure that patients are protected?

We must be cognisant that if it was not for a whistleblower this practice may never have been investigated. This is steadfastly becoming the rule rather than the exception in public life. We welcome whistleblowers coming forward and we actively encourage them to do so but if this culture was so rampant in the system, then there must be robust action taken to ensure that it does not recur.

Sinn Féin has tabled some minor amendments to this motion to enhance it and to try to strengthen it, particularly in the area of transparency for patients. In the first instance, the amendment looks at how dispensing fees could be reduced for patients. In that regard, we recognise that the switching of medications from prescription to a non-prescription basis could help in some small way. It is not a big measure but it could provide some relief. As pointed out by the Minister, the Health Products Regulatory Authority, HPRA, oversees the reclassification of drugs from prescription-only medicine to over-the-counter, OTC, in-pharmacy status and from OTC to general retail sale. In Sinn Féin's Better for Health policy launched late last year, it was noted that at that time the authority had identified 32 products that could be reclassified. These include topical anti-fungal steroid creams and proton-pump inhibitors. It would be interesting to hear from the Minister if that figure has changed or if he intends to act on the recommendations from the HPRA. It is particularly interesting to note that many products currently available over-the-counter from a pharmacist in Britain or in Northern Ireland are only available here on prescription.

The second part of the Sinn Féin amendment is patient-focused. Aside from any reform that comes about as a result of investigations, there is a need to overhaul the culture that led to this situation. We believe there is a need for legislation to oblige pharmacies to inform patients of a pharmacist's dispensing fees, pharmacy services and mark-ups through in-store displays. In this way, pharmacists would be required to use a standard clearly visible template and provide the patient or patient's representative with an itemised receipt following the dispensing of medicines, as a rule rather than on request. If there is greater transparency, patients will be able to determine what fees are being charged and for what item or service. This would, it is hoped, help avoid such situations as has occurred into the future.

As I have said repeatedly, action is needed. I am hopeful that the Minister will follow up and ensure that something happens. Behaviour of the type we have discussed this evening diverts funds from where they are intended and undermines the provision of quality patient care. The losers in this situation are patients, despite campaigns of reduced prescription costs by pharmacies. The HSE and the Minister need to ensure that the health service is better protected into the future.

Deputy Caoimhghín Ó Caoláin

I welcome this motion which arises out of revelations of gross misconduct by a leading pharmacy chain. Lloyds, the State’s biggest pharmacy chain, significantly boosted its dispensing fee income by claiming multiple payments from the State for single prescriptions presented by medical card holders. In recent weeks, the pharmacy made a €12 million repayment to the HSE in settlement of a year-long dispute over fees. This malpractice was uncovered last year following media investigation.

I commend those who brought this situation to light but I also find it extremely worrying that the HSE was clueless to such misconduct. This is not a unique case as I understand that a string of other pharmacies are under investigation for allegedly over-claiming dispensing fees. This motion rightly raises concerns about the HSE's monitoring systems. It goes without saying that in instances where taxpayers' money is at stake, the monitoring system should be watertight. In this instance, the €12 million repaid to the HSE has the potential to make a significant difference, if spent wisely, in a health service that is severely under-resourced. If other pharmacies are found to be operating in a similar fashion, there is a considerable sum of money owed that has the potential to improve the health system, given every euro counts.

The HSE claims the practice constituted fraud. I believe, therefore, that it is reasonable to ask of the HSE how those accountable will be held responsible, if at all.

What system will they put in place to ensure that such fraudulent practices do not happen again?

I also draw the Minister's attention to the amendment tabled by my party, and I note his earlier remarks. I ask all Deputies to vote in favour of it. I commend it to my colleagues in Fianna Fáil, who tabled the substantive motion this evening. The amendment calls for the reclassification of those prescription-only medicines identified by the Health Products Regulatory Authority as suitable for over-the-counter in-pharmacy status, and I call on the Minister for Health to introduce legislation to oblige pharmacies to inform patients of a pharmacist's dispensing fees, pharmacy services and mark-ups through in-store displays so that pharmacists would be required to use a standard, clearly visible template and provide the patient or the patient's representative with an itemised receipt following the dispensing of medicines. I want to use a little of my time to appeal openly and publicly to the HSE and its primary care reimbursement service, PCRS, to approve the use and funding of nabilone for chronic pain management and relief. I use this opportunity to ask the Minister to take note of this very important area. Nabilone is a man-made form of cannabis used to treat severe nausea and vomiting brought about by cancer chemotherapy. It is also a recognised treatment for non-cancer pain. In a 2011 review of nabilone's effectiveness and safety, it was demonstrated that the drug "significantly reduces severity of pain in patients with chronic non-cancer pain", including spinal pain. In February 2016, while we were battling it out in the general election, an article published in Pharmacotherapy: The Journal of Human Pharmacology and Drug Therapy noted that while nabilone is now approved in many countries, including but not limited to Canada, the United States, Mexico and Britain, for the treatment of severe nausea and vomiting associated with chemotherapy, more and more clinical evidence is emerging for its use in managing pain conditions with different etiologies.

I raise this issue because I am at my wits' end as a Dáil Deputy and a spokesperson on health for 14 years. I cannot make any progress on behalf of a constituent, who is at his wits' end in a whole different place to me. In this man's situation, nabilone can be the only life saver, and I do not say this lightly. I appeal to the Minister to intervene and to help secure funding approval for the use of nabilone in the chronic pain management and relief for this man and any others in a similar situation. I have been in touch with the PCRS and we have exchanged correspondence. I have spoken directly and made every appeal imaginable, as have the local pharmacists, the Minister's colleague's counterparts in my home town. They have made repeated efforts to impress the importance of this drug's approval in this particular man's case. An exceptionally small number of people are involved, so while it is an expensive drug comparatively, nevertheless it is not a prohibitively expensive drug. I appeal to the Minister to note the situation regarding nabilone, and I ask him to please come back to me, if he would be so gracious, about this matter at his earliest opportunity.

To reiterate my earlier point, my party welcomes the motion and will vote in favour of it, preferably, if Deputy Calleary will note, with our amendment accepted. We believe it would enhance and strengthen the proposition. I have not used all of my time and I thank Deputy Louise O'Reilly for giving me a little extra.

An Leas-Cheann Comhairle

I call Deputy Mick Barry who will share time with Deputy Gino Kenny.

Deputy Mick Barry

I will start with a quotation from a man whom the House will not hear me quoting too often. A former Minister for Health, Deputy Leo Varadkar, said in December last year that dealing with drug companies brought out "whatever socialist instincts may be buried in me". The Minister, Deputy Varadkar, is entirely right in the sense that putting the activities of the pharmaceutical multinationals under the microscope makes a powerful case against the market forces of the capitalist system, which his party defends, and a powerful case for public ownership organised on a need for need not-for-profit basis, as advocated by the socialist left.

I do not have a large amount of time available, so I will look at the activities of one company, a multinational corporation called Gilead. It has the patent for one of the most advanced treatments in the world for hepatitis C, SOVALDI. Since it patented SOVALDI, its global profits have skyrocketed from $3.6 billion in 2012 to $21.7 billion in 2015. A US-based advocacy group, Americans for Tax Fairness, claimed the company is funnelling money through Ireland. Recently, thejournal.ie carried an article which claimed the company set-up appears to be similar to that used by many other multinationals as part of the double Irish structure. Gilead has half a dozen Irish subsidiaries. One of the firm's main Irish subsidiaries made a full year profit of $1.3 billion in 2012, but paid zero to the Exchequer as the firm was tax resident in the Bahamas.

How does Gilead treat the Irish State in return for such generosity? More importantly, how does it treat hepatitis C suffers in this country? In this Republic, hepatitis C affects approximately 30,000 people. A 12-week treatment course of SOVALDI can be produced by the company for a little more than €150. I understand it is sold on the Egyptian market for $900, which is a significant enough markup. The price for the HSE and the Irish State is not €150 or $900, but €45,000 for one 12-week course of treatment. This is profiteering on a massive scale, and it is profiteering on the back of human misery. It means that only those for whom the illness is very advanced receive the treatment in Ireland. In 2015, approximately 350 people benefited from SOVALDI through the health service. The other more than 29,000 people who suffer from hepatitis C must wait until such time as they get significantly sicker before they get access to the treatment.

We will support the motion but it is very narrow and limited. It does not tackle profiteering on this scale. In reality, what is needed here is not minor change, but system change. This change will be hastened the more people understand the reality of capitalism, an ugly reality revealed all too clearly by examples of profiteering such as the one I have just outlined.

Deputy Gino Kenny

The motion proposed by Fianna Fáil on the Government's responsibility for high drug costs and pharmacy fees is inadequate and dripping with hypocrisy. Since the late 1980s, successive Fianna Fáil Governments have devastated the health service, cutting bed numbers from more than 18,000 to just over 10,000. Our bed numbers per head of population are now 2.8 per 1,000 compared to an EU average of 4.8 beds per 1,000 population.

The majority of these cuts were introduced by Fianna Fáil-led Governments. Equally, staffing levels and the incomes of health services workers were slashed by the most recent Fianna Fáil-led Government. The notion that Fianna Fáil could, in all conscience, criticise anybody for his or her record in the Department of Health is laughable but this is particularly true in respect of drug costs. Between 2002 and 2008 when Fianna Fáil was in power and Deputy Micheál Martin was Minister for Health, drug costs and pharmacy fees in particular and other income earned by pharmacies doubled from €800 million to €1.6 billion.

There is no doubt drug costs need to come down. The spend on them in Ireland is more than double that of Denmark while Ireland spends 77% more per capita on drugs annually than Norway, the richest country in Europe. However, the State still negotiates its prices around more countries where prices are higher instead of where they are cheaper. In contrast with the rest of the EU, generic prices in Ireland are not lower than branded drug prices. The recent €12 million payment to the HSE resulting from an overpayment of pharmacy fees highlights a wider systemic problem in our health service.

To address urgently the problems of access to drugs and the high cost of drugs, we call on the Government to desist from removing drugs from being covered by the General Medical Services, GMS, scheme, abolish prescription charges, set up a national pharmacy co-operative that can offer drugs at prices equivalent to other EU member states such as Denmark and reverse the cuts to both the earnings of health care workers and staffing levels.

Deputy Thomas Pringle

I wish to share time with Deputy Joan Collins. I fully support the motion. We were all surprised when the news broke in respect of repayment of more than €12 million by Lloyds Pharmacy to the HSE after it had incorrectly billed the primary care reimbursement service, PCRS, for dispensing fees. It is a serious issue which needs to be addressed fully within the PCRS to make sure public money is paid out in an appropriate fashion and to ensure companies are not in a position similar to Lloyds effectively to defraud the State in respect of such payments.

The Minister said the investigation was initiated by the HSE. As I understood it, the investigation took place following the intervention of a whistleblower and the exposure of the issue in the media. I wonder to what extent the HSE was involved in identifying this problem in the first place.

Through the scheme, Lloyds Pharmacy was able to increase its dispensing fees by 66%, which is a huge increase, especially during a period the Government was trying to cut euro and cent from payments to social welfare recipients. It would be interesting to compare the number of inspections and controls in place for people who benefit under these schemes with the number in place for big businesses that operate the schemes.

While the money has been repaid to the HSE, it is important that this issue be investigated fully by all the regulatory authorities. The executive has been slow to say whether it will refer this to the Garda fraud squad or the Pharmaceutical Society of Ireland. It says it is keeping its counsel on that for the time being. How long will it take officials to decide that this needs to be tackled? If an individual social welfare recipient had defrauded the State of a sum much lower than this, he or she would be hauled before the courts and held to account. We should expect as citizens that large companies would be treated in the same way and would not be given carte blanche to continue in this fashion.

It is worrying that the Minister said that following analysis and restructuring, the PCRS audit function has been and continues to be strengthened with the development of dedicated resources. What audit function was available to the service prior to this? Has this change been in response to the overpayment of €12 million? More than €2 billion is paid out annually by the PCRS and one would imagine that a robust and comprehensive audit function was in place and the service should not now be appointing inspectors to manage these contracts. That needs to be addressed quickly by the Minister. Will he explain why these appointments have been made only this year and were not made earlier to monitor and control the expenditure of this significant sum of public money?

Deputy Joan Collins

I support the motion. We have witnessed another exposé that sickens many people to their stomachs. Some of the staff are on huge money while many others have had their pay cut by 10%. A large multinational was able to set up a system to generate more income for a period under the HSE's radar. The HSE says that when all the medication was dispensed to a patient on the same date, Lloyds was only entitled to a €5 fee, yet it was claiming an additional €3.75 from the executive. The company increased its dispensing fees by 66%. This is significant increase not to be noticed quickly. I could understand an 8% or 10% increase going unnoticed. Employees would notice a 66% increase in their wages and would quickly ask their employer what the hell was going on.

Questions remain to be answered about where this overpayment came from. The motion seeks detail on how those accountable will be held responsible. That is an important question. The last people who should be held responsible are the staff who were instructed to do this by the top pharmacists. I recall talking to local small pharmacists in Dublin who found it hard to get refunds from the HSE. There were delays of weeks and months.

I am glad the Minister said this issue is being seriously checked by the regulator under the Pharmacy Act 2007. What will follow on from that? I understand that a superintendent pharmacist representing Lloyds is on the regulator's committee. How is that person being dealt with? When the regulator examines the issue, should that person be on the committee? Obviously, he or she should remove themselves from the role.

This issue exposes how large multinationals use schemes such as this to undermine small pharmacies. They have gone to the wall quickly trying to compete with them. The multinationals wipe them out and then provide the only outlets where patients can get their prescriptions filled. Like previous speakers, I support the proposal for a national pharmacy co-operative to dispense drugs to people at the prices they should be sold at. Only last April, the Government diverted €12 million from mental health services to general health services. I hope this issue is brought before the courts and people challenged about it because, as Deputy Pringle said, if a social welfare recipient had inadvertently collected €200 or €1,000, one would not see his or her heels for dust getting him or her into the courts. I hope to see the same vigorous approach to this.

Deputy Michael Harty

I will share time with my Rural Alliance colleague, who will be here soon. From a medical point of view, the excessive claiming of fees by a chain of pharmacies is disturbing and disappointing. Unfortunately, it gives all pharmacies an unwarranted bad name and diminishes their standing in the communities they serve. Community pharmacies supply an invaluable service to their patients, as do their GPs, and we work in harmony and synergy to supply a service to our patients. Any activity that casts a shadow over this essential service is very disappointing and I hope it will not damage the ordinary community pharmacist who supplies a very personal service to their patients.

Blister packing of medication is essential for a vulnerable cohort of patients who need their medication to be dispensed in this manner so that they can take their medication in a structured way. Patients who need this blister packing and the phased dispensing of medication may have cognitive impairment or suffer from confusion. They may have a physical impairment or dependencies in many other ways.

How do these matters come to the attention of the GP or pharmacist? We supply a personal services to our patients and a home help may come to us telling us they have a client who has not been taking his or her medication. It may be on the floor or accumulating in drawers and dressers in the client's home. Doctors may come across it while doing a house call. They may see medication which has not been taken properly or some tablets which have been taken and others which have not. Pharmacists can also pick up the fact that patients are not taking their medication properly so it is usually a decision between the doctor and pharmacist as to whether the phased, blister-packing means of dispensing is instituted. It is a very important part of the medical and pharmacy professions that patients take their medication properly. Blister packing is a labour-intensive service and, as such, should attract a fee that is appropriate to the work done. It is extremely disappointing that this scheme has been used as a money-generating enterprise by some pharmacy chains.

The primary care reimbursement scheme, PCRS, which is computerised, should be able to pick up excessive claiming by individual pharmacies and certainly should be able to pick up excessive claiming by chains of pharmacies. It is obvious that the auditing procedure needs to be strengthened. It is very positive that the excessive claiming has been identified and that fees have been returned to spend on vital medical services. I hope the ordinary community pharmacists are not damaged by this activity and that they retain the confidence of the HSE and the public. Pharmacists who supply a very personal service are essential to the proper running of primary care and it is very important that confidence is maintained in pharmacy.

Deputy Mattie McGrath

I compliment those who brought forward the proposals in this motion. Former taoisigh, Bertie Ahern and Brian Cowen, both told me the HSE would be disbanded. It has not been disbanded though it is a organisation that is totally unfit for the job it has to do. I respect the fact that, as the Minister said, every cent of the money had been paid back and that is right. There also should be interest and penalties because a contract is a two-way mechanism and there should be punishment for people who break a contract. The people on the PCRS work late and not a night goes by when I do not get an e-mail on medical cards. My colleague Deputy Harty, an excellent GP from west Clare, is far more eloquent on the health system and has a greater understanding of it than I. It is clear that chains of pharmacies pull the wool over the eyes of people administrating the scheme. The Minister complimented the people on the scheme for the work they do on a daily basis and I compliment them too. I blame management and senior oversight mechanisms. I blame management in the HSE, of which we now have 40% more in the HSE than we had in 2007. Management numbers are growing very strongly, even though we have had a recession and there were cutbacks which mean we have no front-line nurses or doctors.

All is not well in the HSE - in fact it is extremely unwell. If it was a patient, I would ask Dr. Harty to prescribe some very strong medicine but it is not a patient. It is an organisation that has outlived its uses and overgrown its capabilities when it comes to understanding ordinary human problems. All Members of this House, including the Minister, will have heard very sick people crying in their clinics over medical cards. They have stage 2, 3 or 4 cancer but must be terminally ill or have a diagnosis of palliative care and they go through pain and anguish as they try to get their medical cards. Other cases involve 99 year olds, 98 year olds, 80 year olds and 70 year olds who are €6 over the limit and face trauma and distress at the regimental treatment they get. In fairness to the staff, the system is just rigid but this group was able to pull the wool over people's eyes and engage in racketeering, just like smugglers in Northern Ireland. It is a crime in the same way but is anybody investigating the crime? Are gardaí being called in? Is a file being sent to the DPP? It has been paid back and thank you very much, but if ordinary people, who could not get their medicines or afford prescription charges, pilfered something from a chemist because they needed it, they would be taken to court and gardaí would prosecute them. This is typical of the way Ireland has turned out in the year we celebrate 1916.

The big and powerful can do what they like. We have the insurance industry and we had the Goodman chain in the meat industry. We had to deal with what the banks did to the people. If people are big and powerful, they can do what they like and the Minister will thank them for paying it back. The Minister did not thank them, of course, but thanked his officials for getting it paid back in full. However, it should be paid back with savage, punitive interest so that we could give out a few more medical cards because the volume of money is frightening.

I thank the Minister for visiting Tipperary recently and showing sensitivity and understanding to an institution there. A sister institution, the Aisling, states this evening that it will not be able to continue with the funding stream it has. This racket is going on while ordinary community pharmacists and GPs cannot continue or are being withdrawn and not renewed. They fight with GPs over the rural allowance and over whether it is to be €15,000 or €25,000. We have wonderful GPs and want to keep them but when this goes on at the level we have seen there is something rotten in the state of Denmark. There is something seriously rotten in the HSE that it can be so cavalier. I thank the whistleblower, the journalist and "RTE Investigates" for exposing this but how many more cases are there like this? I am sure there are more and I wonder if any brown envelopes are involved in the HSE. I am sure there are because this could not happen with proper oversight. I know many ordinary people who tender for different services but many of them have been discontinued, such as taxis and hackney services to bring people to their appointments in hospitals or who brought mental health patients from Clonmel to Kilkenny when they closed the institution. One Friday evening they were just discontinued. This was merciless and disgraceful treatment but I am sure these companies give many an official at the HSE a nice trip abroad and other sweeteners for what went on. There should be a criminal investigation into what went on so that the wool can be pulled off the eyes of senior managers in the HSE.

Deputy Seamus Healy

I welcome the Private Members' motion and the debate on the issue of overcharging of pharmacy fees by a large pharmacy chain. It is a very disturbing development and it would appear very senior people in this large pharmacy chain set out to overcharge the taxpayer.

I want to ask the Minister a number of questions.

First, has this matter been referred to An Garda Síochána for investigation? If not, why is that the case and will it be referred? This is a very disturbing development. Individuals regularly come to my office who have bills from the Department of Social Protection for small amounts of money as a result of overpayments that were made to them as far back as ten or 20 years ago. If this matter has not been referred to An Garda Síochána for investigation, it certainly should be, and as a matter of urgency.

I welcome the Minister's indication that this is not a settlement or compromise figure of any kind, but a definitive figure established following detailed investigation of the claims that were made. It is important to thank "RTE Investigates" and the whistleblowers who came forward and ensured that this development became public. How many other lies are there? Are there further ongoing investigations by the HSE relating to other pharmacy chains? If so, when did those investigations start? Are they proceeding or have they concluded? How many other pharmacy chains are involved, if there is such involvement? Obviously, the Minister and the Members wish to be assured that the HSE has staff and procedures in place to police this issue properly and, indeed, the general issue of pharmacy fees. Is the Minister satisfied that the HSE has proper accounting and audit functions in place as a result of this? Is he satisfied that this could not happen again?

This is a very disturbing development, particularly when one considers the situation with the health budget over the last number of years and the devastation the Fianna Fáil-Green Party Government and the Fine Gael-Labour Party Government brought to the health service over the past ten years or so. These moneys could have gone towards dealing with many serious and urgent issues in the health sector to which I intend to refer. I make no apology for mentioning South Tipperary General Hospital in my constituency. That hospital had its budget cut by 25% over those years. It lost €13 million and endured staff cuts of over 100. Despite all of that, it is a progressive hospital. The staff make huge efforts by working above and beyond the call of duty but they are struggling to provide a safe service in a underfunded and under-resourced hospital. The activity levels have gone through the roof and the hospital is bursting at its seams, working at a 120% capacity rate every hour of every day. Indeed, in the medical department the rate is even higher at 150% capacity. That is with average length of stays that are comparable to the lowest national levels.

All of this means that the emergency department - as the accident and emergency department is now known - of the hospital is flooded with people each day. There are 23 patients on trolleys in the corridors of the hospital today. On many occasions during the summer months, the hospital had 30 or 35 patients on trolleys. There were 47 patients on trolleys at one stage. The €12 million relating to the matter under discussion could have gone towards supporting the hospital. Indeed, some of it should go towards that. The hospital is absolutely underfunded. The patients on trolleys each day are located in corridors and in public areas of the hospital near the lifts, vending machines and restaurants. It is absolutely unacceptable. The hospital has a shortage of beds. Its difficulties with under-capacity are accepted by everybody. There is a proposal with the Minister for the approval of a 40-bed modular unit as an interim solution to the problem. I call on him to approve that proposal and provide funding for it immediately. He is due to visit the hospital, at my invitation, on 24 October. I appeal to him to ensure that he makes the money for that unit available. The amount is €2.4 million, a fifth of what we are discussing here in these fees. When the Minister visits the hospital, I ask him to announce the funding for that development and, indeed, capital funding for other upgrading and developments at the hospital.

Obviously, there are other areas to which the moneys we are discussing could have been directed. One area is prescription charges. In the general election campaign of 2011, the Fine Gael Party promised that it would abolish prescription charges, which were 50 cent at the time. By the time it left office, the charges were €2.50 or €25 per month. They are payable by people who have medical cards. They have very low incomes and are unable to pay them. The moneys overcharged on these fees could certainly alleviate that problem. We are all aware of the situation with home helps, who are hugely under-funded and whose hours are cut, the lack of home care packages and the withdrawal of medical cards. These are areas that could and should have received funding and certainly could have been supported by this €12 million.

Finally, I support the proposal in one of the amendments for a national State pharmacy to provide medicines and drugs at cost levels similar to those of our European partners.

Deputy John Brassil

I am sharing time with Deputy Niamh Smyth. I welcome the opportunity to speak on this issue. I must declare my interest in it as I am a community pharmacist, although I practise in a reduced capacity since my election in February.

The over-claiming of pharmacy fees of €12 million by a pharmacy chain is inexcusable and indefensible. Unfortunately, it has the effect of tarnishing the reputation of the 1,800 individually owned pharmacies across the State run by individual pharmacists, which provide a critical service as part of our primary care network. Phased dispensing plays a very important role in the care of our patients. Any patient who has a carer coming to them to give them their medication has been told by the HSE that they cannot handle medications. The role of the pharmacist here is critical. In addition, feeble and elderly patients, patients with Alzheimer's, diabetic patients, psychiatric patients and the methadone programme all avail of this critical service.

The vast majority of pharmacists provide this service having established the need with the patient, his or her carer and the general practitioner. The net results are good drug compliance and the improved health and condition of the patient, with reduced hospital visits. However, when a pharmacy chain or group sees the opportunity to maximise profits and provide the service based on profit rather than patient need, it is wrong and must not be tolerated.

I currently sit on the committee tasked with deciding on a ten-year strategy for the future of health care. I thank the Minister for his earlier comments recognising the fact that pharmacies have and will play a crucial role in the future of primary care. While dealing with this most serious issue of incorrect claims, I hope we do not throw out the baby with the bath water and that we recognise that the vast majority of pharmacists play a critical role and will continue to do so.

At this stage, it would be appropriate to examine the entire payment system across the pharmacy network. There is a need to review the payments made on the GMS, DPS, LTI and high-tech schemes to ensure pharmacists get fair recompense for the hard work and critical service they provide, and to prevent any future recurrence of such abuse.

Deputy Niamh Smyth

I too support the motion. As with colleagues right across the Chamber, I am very concerned about what emerged in the "Prime Time Investigates" programme, namely, that a leading pharmacy chain could abuse its power in such a way and over-claim to the tune of €12 million. I am even more concerned that it could do this without anyone noticing. The HSE needs to outline to us exactly what action it is taking to get to the bottom of this issue. This is taxpayers' money, and it is incumbent on the HSE to ensure it is applying the proper checks and balances when dealing with it. More stringent controls need to be put in place to ensure that these incidents will not be repeated. The waste of public money must not be tolerated.

It is unacceptable to make people who are struggling pay prescription charges. It is disgraceful that those on pensions and social welfare have to pay the charges at all. It is giving with one hand and taking away with the other, and it is adding to the burden of those who are sick. A pensioner must pay bills for electricity, heating and the telephone and must also pay bin and prescription charges, and that is before buying food. A law-abiding pensioner in this country finds it hard to buy a loaf of bread. We hear so much about rural isolation. It features in my constituency, Cavan-Monaghan. The telephone is such a necessity to those living in rural areas. They may not hear from a person from one week to the next. Heat and light are vital needs of those in rural areas.

I disagree with subjecting people on long-term illness benefit to the fees. People are outraged at the latest revelation. They are pushed to the pin of their collar. When we pick up the newspaper and read about one of the leading pharmaceutical chains abusing its power, how can we have faith in the system? We are talking about capping prescription charges when we should actually be talking about abolishing them.

There are a number of independent pharmacists. Previous speakers referred to community pharmacists, who - as is the case with post offices and Garda stations - play an integral role in rural areas and in making up their social fabric. There are many pharmacists acting in the capacity of general practitioners in advising and providing a service to people in rural areas. Most unfairly, they are also being tarred with the same brush as the others as a result of the revelations that have come to light.

I return to Lloyds and its efforts to take advantage of the Irish taxpayer. These funds, totalling €12 million, could have been used to address so many areas of need. They could have funded 600,000 home help hours or provided 500,000 additional personal assistant hours for people with disabilities. The money could have enabled the recruitment of 350 nurses and speech, language and occupational therapists. It could have provided 12,000 medical cards or 1,500 home-care packages. This was all at a time when 30,000 discretionary medical cards were being taken away. The HSE must conclude its investigations without delay and put more robust procedures in place to restore confidence in the system and ensure taxpayers' money is being properly spent.

Deputy Kate O'Connell

I fully support this motion. Like Deputy Brassil, I declare an interest in that I am a community pharmacist and the holder of a contract with the State, as is my husband. I commend RTE for going to the trouble of exposing this. My concerns as a community pharmacist relate to the fact that various proportions of business are taken up with blister packing or phased dispensing. In my business, it is quite a small proportion but it averages approximately 10%.

Consider the matter of fees increasing by 60%. Deputy Joan Collins has left the Chamber. We probably will not agree on anything else during our time in this House. It seems very unusual that this increase would not have set off a red light somewhere. Irregular trends in dispensing practice should be easily identifiable by the HSE and PCRS. Unless there is a particular reason for these trends, such as spikes with fertility drugs beside fertility clinics or drugs to alleviate symptoms of chemotherapy treatment in pharmacies aligned with certain hospitals, it should be very obvious and easy to identify a problem. The PCRS does just not just get a block of data but very detailed data from the community pharmacists on an electronic system. It is beyond me how this could have gone unnoticed and how there was such a definite difference between normal levels of activity and what was occurring in these chains.

From my perspective as a community pharmacist, I wish to address the blatant promotion of the service and the model. Obviously, a company must have been engaged to come up with a flowchart explaining to staff how one could go from a fee of €5 to one of €20 for medication. It was very blatant. I would consider it to be a deliberate manipulation of the ethics by which community pharmacists are bound. Blister packing or phased dispensing is a very labour-intensive process. It involves a very robust checking procedure and it is prone to errors. I have vast experience as a community pharmacist given that I was a locum for many years before opening my own business. In my experience, community pharmacists generally do not overly advertise the process. It is something one would do to help a particular patient. The service is essential for many patients, as Deputies Harty and Brassil mentioned. Generally, the patients that require the service are those with specific needs. They may be visually impaired or have intellectual disabilities. They may just be elderly people on multiple medications in respect of whom adherence to a regime is very important.

I do not wish to repeat what every other Member said. Suffice it to say that as a result of this revelation, small community pharmacists - I consider myself to be one - had issues when competing for business during the recession in this country. We were not able to compete. I do not mean to generalise for all community pharmacists. My experience was that we were not able to compete with large multinationals in tendering for business. As a community pharmacist, I looked at the business the large chains were doing and wondered at times what I was doing wrong that I could not attract the business they were attracting. Clearly, they were working on the basis of different profit margins than the rest of us.

It is also noticeable that a particular chain of pharmacies bought up many pharmacies over the past few years and essentially picked off shops that were in financial difficulties. As someone who is completely dedicated in my professional life to being a community pharmacist, I find it very difficult to stomach that in light of these revelations.

Essentially, many community pharmacists were not dealing with a level playing field. I will not go over everything that the Minister has said but there is scope to negotiate, as Deputy Brassil mentioned, a new fee structure in this sector. There is also scope to negotiate with large operators who are benefitting from economies of scale in their businesses. There is definitely scope to save money for taxpayers.

I would like to say to people and carers who are dependent on this method of delivering medicine that my party and my colleagues from similar backgrounds will work to retain this service for people in the community. I would like no older person in the community to be concerned that this vital service will be taken away from him or her.

When one is dealing with taxpayers' money, it is absolutely essential that robust checks and balances are in place. Many community pharmacists throughout the country do a lot of work for people on a daily basis. As a professional, it breaks my heart to see other members of the profession being tarred with the same brush.

Minister of State at the Department of Health (Deputy Catherine Byrne)

I am speaking on behalf of the Minister, who had to leave. I thank all of those who contributed to the debate and I have taken note of a lot of the issues that were raised, in particular community pharmacists. Many of them have dedicated their lives to working in communities, have gotten to know people and their families and relate to them on a one-to-one basis.

We are all fully aware of the issues raised in the motion and the seriousness of the matter. My colleague, the Minister for Health, Deputy Simon Harris, has spoken in detail and has set out the history of events and the process and measures undertaken to ensure that it was resolved to the benefit of taxpayers and those patients in need of phased dispensing. He also set out the investigation and activities that are under way in the HSE.

Marketplaces are becoming larger, faster and more complex. The increasing complexity and variations of business activities places much greater demands on resources and the capacity of State agencies that engage with commercial providers. As legislators, our duty is to ensure that the HSE is in a position to meet the challenges that all public bodies face in procuring services from private contractors. Probity and governance in the health service are key priorities for the HSE and Government. The importance of investing in probity and control functions is proved by the successful actions undertaken by the PCRS as part of its review and auditing process in this and related cases.

The PCRS is increasing its staffing and oversight capacity and I am pleased to see that this plan is already at the development stage. Of course, the scale of its activities means that staffing resources are not enough on their own. In line with outgoing developments of audits and probity, the PCRS and the Department of Health are considering proposals to improve validation for phased and other dispensing claims.

In addition, the PCRS is working with stakeholders on improving electronic interaction with contractors. This will reduce workloads for pharmacists and improve verifications for the HSE as well as providing for patient care by professional pharmacists. The care and safety of the patients of community pharmacists is, at all times, a Government priority.

I welcome the fact that the HSE is not resting on its laurels and continues to improve the PCRS audit function, with a number of new inspectors and analysts recruited this year. This gives the HSE an increasing capacity in community pharmacy, dental, optical and general practice to analyse data for all contractors to carry out on-site inspections across the country and recruit this claim to payments.

The HSE has done an excellent job in identifying and addressing the issues that have emerged around phased dispensing. The PCRS investigation was very complex and time-consuming and the diligence of the staff in the PCRS in pursuing this investigation should be recognised. This and other actions mean that the PCRS probity activities in 2016 will release €20 million in savings. Not only that, where there are scarce resources they will be promptly directed towards them, as many people have stated during the debate. The patients who need resources will also benefit, as well as clinicians and those who provide services for our patients in hospital.

I am confident that an increased level of oversight will make it easier for proper and professional engagement between all parties in providing services to our patients. I encourage all Deputies to acknowledge this and the work done by the HSE and the PCRS on behalf of the taxpayer. Mistakes have been made but they have been rectified. I thank everybody who has contributed to the debate.

Deputy Robert Troy

I welcome the opportunity to speak in this debate. It is timely and I compliment my colleague, Deputy Calleary, for bringing forward the motion. It is quite evident from listening to the debate that there is outrage from all sides of the House about how a practice like this could be allowed to manifest itself over a number of years through the HSE. It is a damning indictment of the HSE monitoring systems and raises concerns. If this is going on, what other irregularities are happening within the HSE? If it were not for the RTE exposé, would we be any the wiser today?

We might not be any the wiser but based on reports and documents obtained by the Sunday Business Post in 2015, people in the HSE were concerned about phased payments as far back as 2012. They did nothing. A unit in the HSE identified phased dispensing as a risk in 2012. It proposed that the rules around phased dispensing should be clarified. HSE managers drew up circulars to advise GPs and pharmacists how to operate and claim appropriately for medicines that were being dispensed on a phased basis. However, these letters were never sent. That is alarming.

It is alarming to think that genuine concerns were highlighted to the powers that be within the HSE but nothing was done until it was exposed on the national airwaves. Unfortunately, that is not an isolated case. Time and again in this country, some civil servants who have identified ongoing irregularities under their noses turn a blind eye until such time as it comes into the public domain. What are the consequences for people who knowingly and willingly turn a blind eye and fail to do their job? Are there any consequences for somebody who knowingly and willingly fails to do the job?

I am not surprised about this. There was an issue in my constituency a number of years ago where a number of local community pharmacists tendered to supply drugs to a number of community houses in Mullingar. How long did it take that tender to be finalised? It took more than 12 months. It was not even going to be put out to tender. A person identified to me that this new contract was to be awarded without being put out to tender. It was only after I rang the HSE and enquired as to why a new contract would be awarded without going out to tender that I was advised it would be going out to tender in due course. The tender date was altered, not once, not twice but on three separate occasions. I am not casting any aspersions on whoever was awarded the tender. Good luck to them if it was the most appropriate person who put in the best cost. However, I am certainly questioning the professionalism and the manner in which that contract was awarded initially and the subsequent tendering process. While I understand the Minister has confirmed there will be an investigation into what happened in this case, will there be an investigation into contracts awarded by the HSE throughout the State to ensure we are getting value for money?

Some people think it is not their money, but it is. It is taxpayers' money that is being abused and misused. In their contributions, many Members spoke about what that €12 million could do for projects in our respective constituencies for services for the most vulnerable people in society. I recall a question I posed to the Minister of State's colleague in advance of the summer recess with regard to how home help hours have been slashed, and I mean slashed, in the constituency of Longford-Westmeath in the six months of 2016. The Minister of State's colleague informed me they were in the process of rolling out more home help hours. I can tell the Minister of State that if somebody passes away and their home help hours are to be reallocated, only 25% of the hours are being reallocated. That is what is happening. People in urgent need of additional supports are not getting them.

I will give another example. In Athlone, before the summer, a lady who has a Down's syndrome child came to me. The child needs to attend speech and language therapy every week. This lady had been informed that the speech and language therapist was going on maternity leave, to which she is duly entitled, and that nobody would be hired to replace that speech and language therapist for the period that she was on maternity leave. What is that mother to think? How can she work with her child? Her child needs the therapy every week. When I rang the HSE, I was informed that there would be an agency speech and language therapist in place in September. We are now at the beginning of October and, guess what, no agency speech and language therapist. The chairperson of the local Down's syndrome branch came to see me at my clinic last Friday and asked what they are to do with their children. The only person who can understand her child is her mother. Consider the progress those children have made over the period they have the appropriate services in place working with them. Contrast this to the setbacks they will experience as the HSE is failing in its duty and obligation to put the necessary services in place.

I am not criticising the Minister of State personally for that as that is not her fault. However, it is the fault of the management of the HSE. When I speak to the parents of those children who urgently need that service, or when I call out to visit an elderly person living in his or her home and who cannot get access to home help, or when I call out and see a severely disabled man who was recommended 75 hours of personal assistance hours per week but the HSE can only give him 21 hours, what are those people to think? I share only three examples of three cases I am working with. I am sure the whole two days' debate could be taken up by different Members in this House sharing different examples. What are those people to think when they hear that Lloyds Pharmacy can get away with overcharging to the tune of €12 million and they cannot get access to the front-line services they need to have some quality of life?

I ask the Minister of State to allow the motion to be agreed, that unlike previous motions she would not just pay it lip service or simply agree not to oppose it in the House, that the recommendations proposed within the motion would be implemented in order that a situation such as this will never arise again, and that we first of all check there is no other similar scenario going on within the HSE.

Amendment put.

An Leas-Cheann Comhairle

In accordance with Standing Order 70(2), the division is postponed until immediately after the Order of Business on Thursday, 29 September 2016.

The Dáil adjourned at 9.50 p.m. until 12 p.m. on Wednesday, 28 September 2016.