I welcome members of the Irish Pharmaceutical Union, Mr. Seamus Feely, general secretary, Mr. Richard Collis, president, Mr. Karl Hilton, vice-president, Ms Liz Hoctor, treasurer and Mr. Edward McManus, pharmacist. I invite them to make their presentation on The Community Pharmacy: Quality and Timely Access. I draw their attention to the fact that committee members have absolute privilege but the same privilege does not apply to members of visiting delegations or witnesses before the committee. I remind members of the long-standing parliamentary practice to the effect that members should not comment on, criticise or make charges against a person outside the House or an official by name in such a way as to make him or her identifiable.
Irish Pharmaceutical Union: Presentation.
Mr. Richard Collis
I thank the Chairman for inviting us here to talk about the role of community pharmacy in primary care and how this should be developed in the future interests of patients, Government and the pharmacy profession.
My name is Richard Collis and I am president of the IPU. I have been a pharmacist in Phibsboro on the north side of Dublin for the past 25 years. My colleague, Dr. Karl Hilton, who is vice-president, is a pharmacist in Bray. Liz Hoctor, the treasurer of the union is a pharmacist in Mullingar. Edward McManus is a pharmacist in Ballymun. Seamus Feely is our secretary general.
I will begin by giving a background on the IPU and community pharmacy sector in Ireland. The IPU is a representative body for pharmacists. Its primary role is to promote the professional and economic interests of its members. Our membership consists of approximately 1,500 pharmacists, 830 of whom are pharmacy owners and the remainder are employee pharmacists.
An estimated 400,000 people visit 1,300 community pharmacies in Ireland each day. On average, pharmacies are open 55 hours per week and many are open in excess of 90 hours per week. Pharmacists are highly qualified health care practitioners who are easily accessible to the public in cities, town centres, and residential and rural areas throughout Ireland. People do not need an appointment and they have ready access in a familiar, informal environment to expert knowledge about medicines, in particular, and health care in general.
With one pharmacy for every 3,100 people in Ireland, we have the second highest person to pharmacy ratio in the EU. According to a recently published report by the European Commission, we have the most deregulated pharmacy sector. This is a matter of grave concern to pharmacists. It should also be a matter of grave concern to public representatives.
Turning to the broader issue of health care, it is interesting to note that Ireland is currently spending €10 billion a year on health care, of which less than 20% is spent on primary care. As things stand, Government health expenditure is likely to rise by 10% each year just to be able to stand still in terms of service delivery.
Expenditure on health care occurs under three headings - health promotion preventative care; primary care; and hospital specialist care, more commonly known as secondary care. Once a patient hits the secondary care system, health care costs spiral and demand outstrips supply. Cost containment at this level is difficult. However, the development of primary care and preventative care offers huge potential and it is here that pharmacists feel they can be of significant help. Equally, it is only at these levels that Government can develop long-term strategies to control costs in secondary care. My message is simple, namely that the Government can prevent illness and we can help. When illness occurs, the Government must ensure that every effort is made to deal with it at primary care level and to minimise spill-over costs to the more expensive secondary care system.
What exactly do pharmacists do? The primary role of the pharmacist is to safely dispense medicines and advise patients on how to get the optimum benefit from these medicines. Pharmacists also advise patients on drug compliance and check for incorrect dosage and drug misuse. This role is all the more important nowadays as there has been a ten-fold increase in the number of medicines available in the marketplace over the past 20 to 30 years.
As part of their advisory role, pharmacists respond to thousands of spontaneous requests for information from patients on general health issues. However, one of the biggest responsibilities of pharmacists is to deliver various medicine schemes on behalf of the State. These include, the GMS scheme, the drug payments scheme, the methadone dispensing scheme, the high-tech medicine scheme and the long-term illness scheme.
Over time the role of the pharmacist has evolved in response to demographic changes and changes in Government health care policy. For example, Government decisions have meant that there has been a deliberate move away from institutional care to care in the community. Examples of this include the Government mental health strategy and cancer treatments at home. Treatment through these channels is much more cost effective and is the preferred treatment option of patients themselves. This has, however, led to a cost transfer from secondary to primary care which is often overlooked when the cost of GMS services is being reviewed.
Governments throughout the western world are developing the role of the pharmacist in primary care in response to changing demographics, health policies and life expectancy. Our role changed dramatically in the 1970s with the advent of the GMS and more recently with the 1996 contract which defined the role of community pharmacy.
I would now like to talk briefly about the potential to further develop these services. The IPU would like to see medicines management initiatives, pharmacist prescribing for minor ailments, generic substitution and structured health promotion services. I will now look at each of these cost saving initiatives individually, beginning with medicines management. The objective of any review of expenditure on medicines must be to maximise value for money not only in terms of costs, but also in terms of health outcomes. A strategic approach should be adopted which addresses the wider issues of usage, compliance and support for patients. On this issue the National Medicines Centre in St. James's Hospital stated: "The focus of concern for decision makers should be the value derived from drug therapy rather than drug expenditure alone."
In Ireland, once a medicine is dispensed, there is no structured follow up on drug compliance or wastage. In this context, we are proposing that a one-on-one medication review should be undertaken by a pharmacist in co-operation with a patient who is on a complicated medication regime. A pharmacist will review a patient's medication to identify any problems that might have arisen. It is most likely that these would occur in elderly patients or those who suffer from chronic conditions who are taking many medications. The purpose of this intervention would be to improve compliance, reduce leakage to secondary care and reduce wastage.
Recent WHO figures show that up to 50% of all patients do not take their medicines as prescribed. Last year the South Eastern Health Board ran a campaign called Dispose of Unused Medicines, or DUMP, in its area which resulted in over half a tonne of unused and in-date medicines being returned by members of the public to pharmacies over a three-week period. It is clear that there is a major problem with compliance and wastage in the system.
There is a considerable body of international evidence to suggest that pharmacist interventions through medicines management initiatives lead to clear, quantifiable savings. In Australia the government provided funding for pharmacists to provide domiciliary medication reviews which resulted in a net saving of 100 Australian dollars per review for each patient.
The second area in which pharmacy services could be developed is prescribing for minor ailments. There are many families who find themselves marginally above the GMS eligibility threshold. For these people a sick child can mean a real financial crisis. Basic medical costs can be up to 40% of the weekly wage of an ineligible family. In many instances patients or their carers visit the community pharmacy before their GP to receive advice on the most suitable and cost-effective way to treat a particular medical condition. Often pharmacists can treat these patients from the range of medicines currently available to them but more could be done if structured protocols were put in place for pharmacists to treat conditions such as minor skin infections and uncomplicated respiratory and urinary tract infections.
The law should be changed to allow pharmacists prescribing rights in certain narrow and well defined circumstances. This would improve efficiency and also enable patients to have direct access to medicines and antibiotics for minor ailments. It would also require training for pharmacists and carefully developed criteria and guidelines, such as those being developed for nurse prescribing pilots, to ensure that the appropriate treatment is initiated and that best practice is maintained. Allowing pharmacists more discretion in this area would help those just outside the medical card threshold to access services and allow GPs' surgeries and accident and emergency departments to deal with more serious matters. Pharmacists should also be allowed to dispense pharmacy-only products to medical card patients without the need for a prescription.
The role of the pharmacist as a prescriber has been developed in the UK and elsewhere with considerable success. As the committee is aware, bacterial resistance to antibiotics is an ever-increasing problem and we have no desire to contribute to this issue. We are not looking for carte blanche to start handing out antibiotics left, right and centre and nor are we looking to usurp the role of the GP. We believe that pharmacists, given appropriate training and guidelines, are in an ideal position to treat routine ailments.
The IPU recognises that increased usage of generic medicines can make a contribution to cost containment. This process must be managed carefully to guarantee patient care. Community pharmacists in several European countries are already assisting in this context. Figures from March 2003 show that in Finland generic substitutions were made by pharmacists on 14% of all prescriptions, leading to savings of €40 million. This represents 5% of the total drugs bill.
Figures presented by the National Centre for Pharmacoeconomics in St. James's Hospital in 2003 showed that an annual figure of €6 million could be saved by substituting generic drugs for 11 of the top 30 drugs of highest cost to the GMS, where a generic equivalent was available. In this context, it is worth noting that less than 40% of all medicines dispensed on the GMS have a generic equivalent, making generic substitution for the other 60% impossible. A generic policy will not lead to massive savings in the system but can contribute to overall cost containment. If the State decides to move towards generic substitution, this can be done effectively by pharmacists. Legislation will need to be enacted to allow this to happen and we strongly favour such a change in the law.
It has long been accepted that prevention is better and cheaper than cure. International evidence has shown that health promotion activities carried out by pharmacists have been cost effective for both individuals and the wider community. These activities include promoting health and well-being through nutrition and physical activity; preventing illness through smoking cessation campaigns and immunisation; identifying ill health through screening and diagnostic testing; and contributing to maintenance of health for those with chronic or potentially long-term conditions such as diabetes, asthma and hypertension. On behalf of the IPU, I congratulate the Minister for Health and Children, Deputy Martin, on his anti-smoking initiative. We believe this will contribute significantly to the health of the nation.
The Government must develop a structured and well-organised health promotion and illness prevention strategy. Community pharmacists are best placed to make a valuable contribution to this most effective yet underdeveloped part of health care. While much lip service has been afforded to this part of health care, there is no clear strategy. While this remains the case, the capacity to improve population health and contain costs in the long term, particularly in the area of secondary care, will be extremely difficult.
Community pharmacists are in a prime position to work with Government to improve efficiencies in the system, optimise patient care, minimise costs to patients and generate savings for the State that can be sustained year on year. Taking all the initiatives I have outlined here this morning and extrapolating figures from international studies, we estimate that the potential exists to realise annual savings of up to €100 million. This can only be done by a profession that is regulated to deliver a personal service and continuity of care. This is why we strongly believe that the Government must legislate immediately to ensure that pharmacy ownership stays in the hands of pharmacists, as is the case in 11 of the 15 EU states. This will ensure the best professional standards and offer the best value to patients and the taxpayer. Without such regulation, the ability of the Government to deliver the type of pharmacy services that are needed by patients will be significantly reduced. There is a clear need for Government to develop a broad-based strategy for community pharmacy, as has happened in many jurisdictions, most recently in Northern Ireland. I have a copy of the strategy issued by the Northern Ireland Department of Health, Social Services and Public Safety for pharmacy services in that jurisdiction.
I thank the Chairman and the committee for inviting us here today. I, along with my colleagues, will be happy to deal with any questions on the issues raised in our submission or any related matters.
I thank Mr. Collis. We appreciate his thought-provoking presentation. I am sure members have many questions to ask. We have two GPs on the committee and I will be interested to hear their responses to the document.
Has this recommendation been brought to the attention of the Department of Health and Children? Are GPs over-prescribing for patients? What control exists for the medicines being prescribed and time limits on prescriptions? The claim was made that there is massive waste but that would not be the case unless over-prescribing is taking place.
I would also like to hear more about prescribing being a role for pharmacists, the dangers that might arise as a result, the experience in Britain and how the organisation responds to the claim that it is part of the rip-off culture in Ireland because there is substantial evidence to suggest over-charging in the sector.
Mr. Collis
The rip-off accusation has been put to me time and again on the radio and television. There is not a scintilla of evidence to indicate there is any rip-off in the pharmacy sector. The prices of medicines are controlled by the Government. As a Deputy said at a meeting some weeks ago, the pharmaceutical market is a contrived market but the structures were put in place by the Government. Of all medicine dispensed in the State, 70% is dispensed without a mark up, just a professional fee. That gives a better flavour of what is happening in pharmacies than the lurid statements I have heard in the last two years. I have asked these commentators for evidence and none has been forthcoming.
The cost of medicine in the pharmacy here has been contrasted with the cost in Northern Ireland or Britain.
Mr. Collis
The cost of medicines in this State are based on a basket of costs across northern Europe. There is a fluctuation of 6% but there are medicines here that are significantly cheaper than in Britain, although there may also be medicines that are significantly dearer. The State put that structure in place to control costs. Looking at the free market in America, the cost of patent medicine there is six to eight times higher than here. It is a contrived market but that is not related to us - the structure of medicine costs is controlled by the State.
Mr. Karl Hilton
Pharmacists would like to get involved in medicines management. There is considerable international evidence to show that when a pharmacist becomes involved in a one-on-one review of medication with a patient, considerable savings are made, not just in drug costs but because the patient will not have to use secondary care as often. Medicines management is an area where we can be of assistance. It has been shown in Britain that 80% of all medicines are prescribed on repeat prescriptions. When pharmacists become involved in reviewing these repeat prescriptions with patients in a patient medication review, savings of 18% can be made on the cost of medicines. If the total drugs bill in the State is €700 million, excluding hospital drug costs, and extrapolating the British evidence, involving a pharmacist will save up to €100 million.
This will require a strategic approach on the part of the Government. At present pharmacists give advice free of charge on a daily basis. PricewaterhouseCoopers has shown that the activities in which pharmacists are involved on a daily basis for which we are not remunerated save the State €150 million per year. We call those clause 9 activities because they are part and parcel of our patient care clause in our contract with the health boards. There is, however, more that pharmacists can do but it will require a strategic approach and partnership between us and the Department of Health and Children.
The Chairman asked if we had made these submissions to the Department. As long ago as last November we made a value for money submission to the Department but we have not had any great response from it on this.
I welcome the delegation. I will play devil's advocate in my questions. All of us were shocked by the figures on medicines management. It is not the first time we have heard about the half tonne of medicine that was returned unopened in a three-week period in one health board area. Was there any attempt when the return scheme was under way to identify who was doing this and why? Were they people who had paid for the medicines or were they GMS patients? Were they returning them because they felt they did not need them or they were the wrong drugs? Is there any explanation for such huge amounts of medicines being returned unopened?
My instinct during the presentation on medicines management and follow-up with patients was to ask what is stopping pharmacists. Why do they not get on with follow-up if they are really conscious of the problem of lack of compliance and knowledge?
On doctors having the sole right to prescribe, as a consumer I am in favour of extending that for certain strictly defined areas. There is, however, a potential conflict of interest where the seller of the product is also its prescriber. At the moment there is a disincentive for doctors to prescribe because they benefit if they spend less money on prescription drugs. Such a mechanism could not exist if pharmacists were prescribing. It gives them the right to create their own demand.
As Fine Gael health spokesperson, I have been getting letters from young pharmacists who have trained abroad and for some incomprehensible reason are not allowed to operate their own pharmacies. This refers to a derogation of which Ireland avails. Perhaps Mr. Feely could explain this and give the union's view on what appears to be an untenable restrictive practice in an area characterised by many restrictive practices. I refer to medicine in general, not specifically pharmacists.
Mr. Seamus Feely
I will deal with the last issue first. The derogation was introduced in the 1980s to level the pitch for pharmacy regulation across Europe. Many countries had very strict regulations governing the opening of new pharmacies, the type of criteria we had under the 1996 regulations, while other member states did not have any such regulation. The purpose of the derogation was to ensure that countries which did not have any regulation were not disadvantaged in the free market that operated throughout the 1980s and 1990s. Ireland is now the most liberal market in Europe and we are disadvantaged in a European context in that any pharmacist or individual can come from another EU member state and open a pharmacy here. An Irish pharmacist, however, does not have the right to do that in Germany, France, the United Kingdom or elsewhere in Europe, which puts us at a disadvantage. The problem of the derogation in the Irish context is that many Irish pharmacists had to go to the UK to study pharmacy because until two years ago there was only one school of pharmacy here. Consequently, many are caught by the derogation but only to the extent that they cannot open a pharmacy.
This affects many of our members who do not wish it to go. The union's view is that if we have a regulatory system that puts us on a level playing pitch with other jurisdictions across Europe, the derogation can go in the morning. The decision, however, is not ours. It is primarily a matter for the Department of Health and Children and the Pharmaceutical Society of Ireland both of which, in addition to the Minister, have said that they are not in favour of ending the derogation because there is no fitness to practice legislation here. The pharmaceutical society has no power to control entry or set standards for pharmacists coming in from other jurisdictions and the Mortell reportconcludes that the derogation should remain until such time as there is proper fitness to practice legislation on the Statute Book. We do agree with that approach.
Is Mr. Feely saying that a German or a Dutch person can come here and start a practice but an Irish person who has trained in Germany cannot do so?
Mr. Feely
Yes. An Irish person who has trained in Germany cannot do so. Equally, an Irish pharmacist cannot go to Germany and open a pharmacy because of regulation there. The derogation operates in addition to the regulations in eight of the 15 member states. It is not unique to Ireland.
Whom does the derogation benefit and how?
Mr. Feely
It creates some balance in market regulation across Europe. The Irish market is the most liberal in Europe and the derogation gives Irish pharmacists some protection.
Mr. Feely should answer my question. How does it achieve that?
Mr. Feely
If pharmacists come in from another country, under the derogation, they cannot open a pharmacy here.
Does that mean that a German-trained German pharmacist cannot come in here?
Mr. Feely
Yes.
Can a German-trained Irish pharmacist come in here? I do not understand this issue.
Mr. Feely
I can start again if the Deputy wishes.
Deputy O'Malley should note that the reverse is the case.
Mr. Feely
Yes, it is the other way around. If an Irish person is educated in Germany and returns to Ireland he or she cannot work in the Irish market under the derogation. If an Irish pharmacist educated in the United Kingdom or in Ireland wants to go to Germany, France or any other EU country and open a pharmacy, he or she is prevented from doing so by regulation in those countries.
Can the person open a business in those countries?
Mr. Feely
No. In countries such as France and Germany only pharmacists are allowed to open pharmacies. Many of them operate the derogation as well so there is a dual protection. We are amazed that there is not more concern about the risk to us from the accession of new member states. Ireland will then be the only country welcoming pharmacists from all other member states with no regulation.
That is the anomaly.
Mr. Feely
Yes, and it affects our citizens because they could not receive training here. Many of our members affected by this feel that the future of their profession is at greater risk if the derogation is removed than if it stays. Most are in favour of retaining the derogation until we have harmonised regulation across Europe and proper fitness to practice legislation here.
This involves a public health and safety issue. GPs contact us frequently because they cannot conduct conversations with pharmacists who do not speak English. This is very dangerous and it is time it was addressed.
Am I correct that in 18 months time there will be a pharmacy Act which the Department is drafting and that derogation will be considered in this regard?
Mr. Feely
Yes.
Mortell and his committee viewed it as unfair and thought it should not exist. In 18 months time there will be much debate about this, but whether there will be change is yet to be seen.
Mr. Collis
I hope we can depend on the Senator's support for the Bill. When I qualified in 1974 there was talk of a pharmacy Bill to be introduced that year. There is no pharmacy Bill. The legislation governing pharmacy here is antiquated, backward and not suitable for current circumstances. One of the problems is medicines management. There has been a tenfold increase in the number of medicines available since the 1970s which has caused great problems for consumers. Elderly people in particular who are on five or six medications find it confusing. That is why a DUMP campaign releases a half tonne of in-date unused medicines and why we need structure.
Mr. Feely
I would like my other colleagues to comment on the remaining three issues raised by Deputy Mitchell.
Deputy Mitchell mentioned the role a pharmacist might have in prescribing for minor ailments. We already prescribe for conditions such as hay fever. We seek an extension of that role to deal with minor skin infections such as impetigo, which is a bacterial infection treated with an antibiotic cream. If a mother comes into the shop with a child who has this infection, I must refer her to a GP. Allowing pharmacists prescribe for minor ailments in a very structured way will give GPs more time to deal with acute cases. We propose the model used in the United Kingdom. Last month, when the first batch of pharmacist prescribers graduated, Ms Winterton, the UK Minister of State for Health, said:
Extending prescribing responsibilities to pharmacists will make getting the right medicine easier and more convenient than ever before and will help to reduce the burden on GPs by giving them more time to deal with acutely ill patients.
Is she a doctor?
She is the Minister of State for Health in the United Kingdom.
Is she a doctor as well? Is she qualified to make these judgments?
Mr. Feely
She is the Minister of State for Health.
Yes, but is she a doctor? I could be the Minister for Health and Children one day.
Mr. Feely
Our Minister is not a doctor.
If she is not a doctor, she does not have the background——
I presume that Ms Winterton has been a patient at some time. Patients probably are the best judges of who provides the best quality health care.
I agree that pharmacists should be able to prescribe more. I worry, however, because doctors are a gateway control on the costs of prescribing. How are protocols put in place to ensure that this practice is not abused? Ms Hoctor said they exist in other countries.
There will be structured protocols agreed locally between GPs and pharmacists. We do not seek to usurp the role of doctors and as pharmacists and health care professionals we are acutely aware of the escalating drugs bill. We want to contain that aspect. Why would we want to see people going out with sacks full of medicines?
Pharmacists might want that because it is good for the bottom line in business.
Mr. Feely
We are professionals.
I accept that. I am playing devil's advocate.
As a pharmacist with five years' training and ten years' experience, I would be sad if any of my patients who deal with me on a daily basis in Mullingar saw me as a "pile 'em high, sell 'em cheap" outlet. My patients trust me and know that I deal with them with integrity. When they come to me, they get honest and independent advice. I do not deal with the bottom line, but with patients' health.
That is the way a patient views his pharmacist. My concern is that it might change with this proposal.
I would hope not as I believe we already have the trust of our patients. Some patients will ask for Nurofen but, in conversation, one realises that the patient is asthmatic. As Nurofen is not suitable for asthma sufferers, the pharmacist will advise Panadol which the patient may have at home. The patient walks out of the pharmacy without having made a purchase but having received free, sound and independent health advice.
I welcome the delegation from the Irish Pharmaceutical Union. Am I correct in describing the Irish Pharmaceutical Union as a trade union? How many pharmacists in the State are members?
Mr. Feely
The figure for proprietor-pharmacists comes to approximately 97%.
What is the Irish Pharmaceutical Union's relationship with the Pharmaceutical Society?
Mr. Feely
The Pharmaceutical Society is a statutory body which is the equivalent of the Medical Council. It is there to impose standards and enforce regulations.
The Irish Pharmaceutical Union, therefore, is the trade union while the Pharmaceutical Society looks after standards. As a GP, I had a great relationship with my local pharmacists and I pay tribute to them.
With regard to the management of medicines issue, elderly or confused patients might not take their prescribed medicines on a regular basis. Does the Irish Pharmaceutical Union see the pharmacist's role as going to the patient's house to assist him or her in taking his or her medicine or is that role more appropriate to the district nurse?
Mr. Hilton
This could be done in the pharmacy setting where the patient sits down with the pharmacist for a 25 minute interactive lesson on the medication, with the patient learning what it is for and checking if he or she is taking it. This could also be done in the home setting. This initiative has already been rolled out in several other countries, most notably Australia with a well-thought out medicines review system in place. In this case, it has been shown that after paying the pharmacist a fee for this professional service, and the GP for his input, it saves 100 Australian dollars. There are definite and tangible savings to be made with this scheme.
Is that not already done when the medication is explained to the patient at the pharmacy?
Mr. Hilton
Yes, but resources have to be put in place to enable pharmacists to spend 25 minutes with each patient. That is not possible under the current system. The Irish Pharmaceutical Union is looking to free up more resources to carry out a more in-depth and structured analysis with the patient.
What exactly is meant by generic substitution? Presumably, most GPs are now prescribing generic medication.
Mr. Edward MacManus
Most GPs are prescribing generic medication but what is needed is a focused controlled campaign. We have seen what happens when attention is put on a particular issue by the service providers. There was a campaign in the mid-1990s to improve generic prescriptions. It worked to a certain extent but it also resulted in many of the drugs becoming uncompetitive. Prices dropped and so the drugs were discontinued with the result that the amount of available generic alternatives dropped, only to be replaced by more expensive drugs. All the drug companies, doctors and pharmacists must come together to organise a system where costs are controlled overall with a win-win result for all providers.
A simple solution to every problem is always wrong. We have come some way towards bringing in generic prescribing but there are a number of problems that need to be ironed out. We must go back to the drawing board to see what can be done to make such a scheme more effective. Despite the increase in generic prescribing, drug costs have increased. There must be more competition in the area. A pharmacist is best placed to advise a GP what drugs are the best value for money and the most effective. There was a report in the UK——
I understand that but take the scenario where a prescriber looks up MIMS to find the cheapest drug. What happens to the role of the pharmacist in the prescription of generic drugs? Is the Irish Pharmaceutical Union looking for the opportunity to give a different generic drug?
Mr. Feely
I am not a pharmacist but my understanding is that when a doctor writes a prescription with the chemical name of the product, the pharmacist collects it for the patient. We are advocating that the law be changed to allow the pharmacist to substitute products where the doctor writes a prescription with a particular brand name. This would be subject to various protocols but would allow the pharmacist the right to substitute a product with an equivalent.
Mr. Hilton
There is no great crock of gold at the end of this generic substitution route. However, there are tangible savings to be made. Estimates have been made that €6 million to €20 million could be saved per annum. This should be under the control of the pharmacist. If generic substitution is allowed, the pharmacist is not only taking into consideration that the drug may be chemically identical but also that any substitution does not affect the patient's compliance. If a substitution is made, the patient is still taking the medicine.
Why would it be worthwhile to substitute one generic drug for another?
Mr. Hilton
There is no advantage in substituting one generic drug for another. However, there are advantages in substituting a generic for a proprietary.
Is that not what is happening?
Mr. Hilton
No. If a proprietary name is written on the prescription note, the pharmacist dispenses it. There are many products where there is a generic equivalent which, with a pharmacist's intervention, could save the State money.
In 2002, there were approximately 3,400 self-inflicted poisonings, 1,400 of which involved paracetamol poisoning. There were 40 liver transplants, the majority of which were the result of paracetamol poisoning, and 9,266 kidney failure cases. Is the Irish Pharmaceutical Union satisfied that the controls introduced in 2003 are adequate to control the sale of paracetamol? Should all paracetamol products be strictly issued by pharmacists rather than over-the-counter in supermarkets?
Like Deputy Devins, I regard my local pharmacist as my friend. I have two local pharmacists who are equidistant from me and they have been very good allies and supports in the past. I regard them as very much part of the team and I greatly value local pharmacists. I am also a dispensing doctor, or was before I went into politics. It has been stated that pharmacists work long hours but if I was at home, I would be working 168 hours per week, which is as much as possible. I have an insight into dispensing. I am very interested in the concept put forward by the delegation and I would like their opinion on a number of matters. Is it correct that if my son was to go to England, France or anywhere else and qualify as a pharmacist, he could not return to set up a pharmacy in Ireland?
Mr. Feely
Yes.
That is very unfair. Would the delegation agree that this needs to be changed?
Mr. Feely
Yes, we fully agree. We merely ask for a level playing pitch in terms of regulation across Europe. It is also extremely unfair that Irish pharmacists do not have the same right to operate in every other member state. Citizens of those states can open pharmacies in Ireland, but an Irish qualified pharmacist cannot open a pharmacy in other member states. Not only is this unfair, but it exposes the Irish pharmacy sector to consequences which are undesirable in the long term for patients and for access to pharmacy services.
I went to France last year with my family and bought a drug in Paris which cost about one third of what it costs in Ireland. I know the price in Ireland because I would have dispensed that drug myself, yet it cost only a third of the price in cosmopolitan Paris. I could not understand it. Irish pharmacists say the price is Government-controlled, but what can the Government do to ensure that people can buy drugs at the prices available to French EU citizens, for example?
What is the delegation's view of dispensing doctors? Such doctors work in places where no pharmacist will go because it is not commercially viable for them to do so. Some years ago, the Government tried to abolish dispensing by doctors, a policy quickly dropped because of public outcry from people who wanted a local service. The IPU did not come out in support of dispensing doctors at that time. I would like to hear the delegation's view.
It is important that the delegation is in attendance because pharmacy is currently at a crossroads. It is enlightening to hear that legislation has been promised since 1974. It is important that the legislation is brought forward quickly because change is clearly necessary. The notion of derogation is utter nonsense and quite ludicrous.
I would like to hear the views of the delegation on the role of the Government in pushing up drug prices. I accept that it is not really the fault of the pharmacists in terms of the contract agreed regarding price mark-ups. If I was the Minister for Health and Children, I would seek to reduce the drugs bill by renegotiating the mark-up price agreement. The mark-up is outrageously high. As Deputy Cowley pointed out, the transparency of euro prices in the EU makes the mark-up very clear. We can all try to procure our medicines by means of the Internet, if that is legal.
Mr. Feely
It is not wise.
I suppose it is not, but if one has a doctor's prescription and knows what one wants, buying it on the Internet is a great deal cheaper. Pharmacists and, more importantly, the Government need to be aware that the high mark-up needs to be renegotiated. I thought it curious that Mr. Collis said that 70% of medicines do not involve a mark-up, but merely a dispensing fee. How much is that fee? Pharmacists are entitled to a fee, but is it a standard one for each item?
I am worried about the fitness to practice legislation. Would Spanish doctors or pharmacists, for example, view Irish standards as inferior to theirs? The notion of that legislation scares me and makes me wonder about our standards and possible problems in that area.
In eleven of the 15 EU countries, to operate a pharmacy one must be an owner-pharmacist, while Ireland is one of four EU countries where one does not need to be an owner-pharmacist. The IPU believes that anyone who runs a pharmacy should be a pharmacist. I ask the delegation to comment on that aspect.
I welcome the delegation and I acknowledge the excellent role pharmacists play in the community. Each of us has a special relationship with his or her pharmacist, wherever they might be. I know that the IPU made a presentation to the Department regarding prescribing rights in certain well-defined areas and circumstances. That presentation was clearly much broader than what the delegation has said to us today. Will pharmacists be trained and qualified to examine patients, to take histories and keep records in the same way as doctors and consultants? Mr. Hilton or perhaps Mr. Collis talked about setting aside perhaps 20 or 30 minutes to sit with a customer and inform him or her of how to take the medication and so on. We all know that time costs money so will there be a charge for that service? If so, who will pay it?
The Medical Council recently issued its new guidelines for the profession. I was chairperson of its ethics committee and I know there are huge restrictions on how the profession interacts with pharmaceutical companies and on its relationships with pharmacists. If I arrive as a patient, there is an onus on my doctor to declare his or her interests with a pharmaceutical company, or with a pharmacist in the town or country. Perhaps the following question is a little provocative, but it plays on my mind. Is there any evidence of any sweetheart deals being done with pharmaceutical companies and with pharmacies regarding prescribing, if the pharmacies are given prescribing rights?
Mr. Collis
In his question about paracetemol, Deputy Neville raised an important issue. There is no absolute protection against paracetemol poisoning. All we can do is take steps which make it as difficult as possible. However, there is data to indicate that the incidence of suicide by paracetemol is much less frequent in states where those medicines are confined to pharmacies. In France, for example, where paracetemol is confined to pharmacies, its use as a suicide-inducing agent is much lower than in Britain. For very good health reasons, the IPU believes all medicines should be confined to pharmacies.
Deputy Devins took the Chair.
Mr. Feely
I would not know where to begin regarding the differing prices for drugs across Europe. There are huge variations in price. When the Government meets the pharmaceutical industry to set the prices for prescription drugs, it bases them on the average prices in five north European countries, including the UK. There are products for sale in some countries for which we as pharmacists pay five times more than the price at retail levels in pharmacies across Europe. An effort is being made at European level to get a common pricing structure across Europe. There is something known as the G10 process. Essentially it is a drive for a level playing field or a levelling of prices across member states for all new medicines coming on the market. One of the problems with medicines, of which I am sure members are well aware, is that almost 70% of the revenue for pharmaceutical companies comes from four countries, most critically from the United States, which accounts for 50% of the revenue of all pharmaceutical companies. An issue is now arising through the World Health Organisation and the World Trade Organisation that the Americans have some concerns about European Governments restricting the prices. They believe that the market should dictate the price. Owing to the controls in all European countries, the Americans feel that they are paying an unfair price for their own medicines, which are five times higher than they are in Ireland. It is a very complex area, but I know the agreement between the industry and the Department is up for review this year and talks will get under way on it by July 2004. We do not know where that will lead.
Mr. Hilton
On the issue of pricing and the points raised by Deputy O'Malley, I reiterate that 70% of all medicines dispensed on State schemes do not attract a mark-up. The question was asked about the fee for dispensing those items. The standard dispensing fee is €2.98. The cost price of many medicines is much higher - in the order of multiples - so the return to the pharmacist for dispensing a medicine which could have a cost price of €100 to €300 is €2.98. However, regarding transparency, we can safely say that the margin on GMS prescriptions is of the order of 17% or 18%. That is the type of margin for 70% of all medicines dispensed on State schemes.
I would like to highlight the risks of buying medicines on the Internet. One is buying products from a source which is unknown. The safety and quality of those medicines certainly cannot be guaranteed. The other issue is that there is evidence that buying medicines over the Internet is more expensive than in community pharmacies in Ireland. Regarding the margins that pharmacists are paid for private schemes, one must ask what type of pharmacy service we want in this country. Do we want a volume-driven, "lick and stick" type of service, where the pharmacist spends his day on a conveyor belt in the dispensary just shoving medicines out, or do we want one where pharmacists interact with patients and spend time with them? Obviously, the latter is preferable. That requires resources and the net margins that pharmacies make have been shown to be approximately 7% to 10%. The net margin that pharmacies obtain in Ireland is well in line with those of other European countries. The growth margins are much less than many other retail sectors in Ireland. In pharmacies we have added value with the input of health professionals.
Regarding the mark-up, if one examines private prescriptions and the price paid, one sees that there is a 100% mark-up. It looks like that anyway.
Mr. Hilton
On private prescriptions there is a 33% margin. They account for 30% of all medicines dispensed on State schemes. As I said, the other 70% are dispensed with no mark-up at all. It is purely a standard fee of €2.98. We accept that the GMS scheme is currently operating at below market cost and is being subsidised by the private schemes. That is something that——
Are deals done with different drug companies to get different mark-ups from them depending on what drug one gets in? Let us suppose that a doctor prescribes ampicillin. One could have a choice of different types to prescribe. Would a pharmacist not do a deal with different drug companies to get drugs at a certain cost? That covers the GMS, but for private prescriptions one would have a 100% mark-up, since, as Mr. Hilton said, it subsidises the other side of the business.
Mr. Hilton
My primary concern is the 10,000 drug entities on my shelf and, to be perfectly honest with the Deputy, I do not have time for that. I must ensure that I have the correct medicine for the correct patient at the right time.
Mr. Collis
There is remarkable uniformity between the generic prices. It is not true to say that generic medicines are only dispensed on the GMS. They are dispensed right across the board.
I did not say that.
Mr. Collis
I thought the Deputy did.
No, what I said was that if a doctor prescribes a generic product, it is up to the pharmacist which one to give, and there are several options. The pharmacist therefore has the option of being able to increase his mark-up by dispensing a certain type that he might get at a better price.
Mr. Collis
I will go back to the point I made. There is remarkable uniformity among generic prices in this country. There is not a great difference between the price of ampicillin that one would get from one drug company and another.
I know that, but does the pharmacist not do a deal with a specific manufacturer?
Mr. Hilton
I accept that there are certain generics on the market and that a pharmacist, as a business person, can try to get the best deal. However, as I said, 70% of all medicines prescribed on the GMS do not have a generic equivalent.
Many GPs would prescribe generic products too. Mr. Hilton made two very important points. The first was that the primary care service is underfunded. I absolutely agree with that point. Savings can be made by supporting anything in primary care to keep people out of secondary care. I take that point. GPs are very good and diligent prescribers, as I am sure Mr. Hilton would agree. They would in turn keep an eye on the people returning to them every month and ensure that the person is complying with the medication. Otherwise they will not get the benefit of the medication. There is a limited number of generic products that one can prescribe. I believe Mr. Hilton mentioned the figure of 40%.
Pharmacy is a high-cost business. Some drugs go out fairly fast, but with others one might get in a 100 pack costing €200 or €300 for one patient. That might be the only time that one uses it, with the rest of the drug going out of date. It is swings and roundabouts; one wins some but loses on many others. It is also a very high-cost business for wages - one of the highest in the EU - and that must be borne in mind.
Deputy Cowley mentioned dispensing doctors. It is important that we have a clear distinction between the roles of pharmacists and doctors. The ideal situation is that there is a pharmacy in every community that needs one. However, we realise that is not always possible. The likes of Deputy Cowley would provide an excellent service in that regard where necessary. We are concerned, however, that we might take the route of other countries where pharmacies have closed down in rural areas as a result of deregulation and competition from chains where there was a concentration of pharmacy services in towns and larger suburban areas in which there was already a supply to the detriment of rural areas, which did not have that service.
I had a French pharmacist working with me last year and she was amazed at some of the services we provide in this country. They have the basis of some of them there, but we have advanced in many areas, especially in medicine management. I have an example I can give members. One gentleman was on about 15 different medications and he was completely confused as to how to take them. The doctor, in consultation with us, came up with a mechanism which allowed the patient to take the medicine safely. It also reduced costs because if a patient is on a great deal of medication, it is difficult for him or her to control it. We have the greatest respect for doctors and seek to complement their role rather than denigrate it in any way. As time has moved on, in every sector of life, there is no comparison between now and ten years ago. Yet in order to maintain patient care, which is the ultimate goal for doctors or pharmacists, we must move with the times and expand our roles.
I apologise that I had to leave the meeting to attend another. I consider the pharmacy outlet part of the infrastructure of an area. It is extremely important. I carry no torch whatsoever for the chains and want to make that abundantly clear to everyone in the room and outside. It has been brought to my attention, on more than one occasion, that some years ago a person opened a pharmacy outlet. This was followed quickly by the opening of another pharmacy outlet by an individual who had a number of pharmacy outlets. Following the closure of the first pharmacy, the other pharmacy closed shortly afterwards. In recent years, in an area where I consider there should be a pharmacy, an application was made for a pharmacy contract but it has not been put into force. In other words, there is a large area that is not being serviced by a pharmacy outlet. I do not approve of that situation. That is the type of practice that brings the pharmacy profession into disrepute. If there is an established need for a pharmacy outlet, that need should be serviced by the opening of a pharmacy outlet.
In its submission the delegation mentioned stepping into the role of prescribing or dispensing drugs that normally would be dispensed by general practitioners and others. I do not wish to differ with the Chairman, Deputy Cowley or Senator Fitzpatrick but I do not see a huge problem with that, subject to certain criteria being satisfied. The local pharmacist has a pivotal role to play not only in the dispensing of medication, but in the advice he or she gives to clients. That would not be the case with multi-outlets. In many instances, an individual would be in charge who would not be indigenous to the area. From my experience, having worked in the health area, the local pharmacist has played and will continue to play an important role not only in the dispensing of medication, but in advising people of the content, the lethal dosage and what to watch out for and because they are local, they know their clientele. That is the reason I am not disposed towards pharmacy chains. That is not to say that they do not have a role to play, but the local pharmacist, in tandem with the local general practitioner, has an important role to play. I would like that role continued and enhanced.
Unlike the Chairman and Deputy Cowley, my local pharmacist, Mr. Richard Collis, is present and I welcome him.I agree that pharmacists should prescribe for minor ailments. I was a general practitioner. Has the delegation considered the insurance implications because insurance premia will climb through the ceiling if it goes down that road? I do not have any problem with it. Society has changed so much in the past ten years in the area of litigation that one could face a large problem.
Mr. Collis
In regard to the structures and priorities being put in place, the insurance issue would be looked at very carefully.
Will I get some answers to my questions? I am only a Senator but I would like some answers, please.
Mr. Hilton
The Senator asked about the 20 to 30 minutes we propose spending with the patient for medication reviews. Obviously, there has to be a charge for this service as a pharmacist is making his or her time available. There are definite downline savings for the State as a result of these medication reviews. It has been shown that the net saving per medication review in Australia was 100 Australian dollars per review. That does not take into consideration the downline cost.
Who will pick up that charge?
Mr. Hilton
The State is saving a good deal of money as a result of this medication review and, therefore, the State should pay for it.
My other question was in connection with the union's relationship with pharmaceutical companies. I take it there is continuing professional education.
Mr. Feely
The continuing education is funded directly by the Department of Health and Children and is run independently of pharmaceutical companies. As a union, in terms of our own promotional campaigns, we have often been approached by pharmaceutical companies to lend our weight to, for example, the no smoking campaign which is currently running in all our pharmacies, but we declined the offer and decided to fund it ourselves. We have asked the Department to assist us with it. The attitude at union level would be that we have always funded such campaigns individually or sought help from the Department.
Did Mr. Feely say that CME is funded by the Department of Health and Children for pharmacists?
Mr. Feely
Yes.
That is more than the medics got.
Mr. Feely
It was part of the contract negotiated with us going back to 1996 when the Irish centre was set up. It is funded by State and it provides a whole range of courses. We have a high participation rate of the order of 60%.
Regarding Senator Glynn's point about the pharmacies, in a way he is almost making the classic case for regulation because the irony of the 1996 regulations was that because one could not open pharmacies in areas where there were already services, it pushed services into the type of areas to which the Senator referred. Unfortunately, since the regulations were dropped, any new openings have all been on the high street or in major supermarkets. People are not queuing up to go into small towns and villages. The other problem in the deregulated market is that the market for small pharmacies has practically dried up. We estimate there are approximately 300 or 400 small pharmacies in the country that may not survive into the next generation. That is a huge issue.
The first example I gave was pre-1996.
Mr. Feely
Unfortunately, we will see those practices in the deregulated market. That is the price of a free market.
We are all aware of Ryanair and competition where prices are reduced. Against that there is the public service obligation as regards rural areas. People had a facility in rural areas. The reason there are not pharmacies in such areas is that it is not viable. The delegation talked about prescribing for minor ailments and for those just outside the medical card threshold. If the Government was to provide 200,000 medical cards that would solve the problem because there are people with children who are on the breadline and below the minimum wage who are in deep trouble. On the issue of pharmacists prescribing, vets and pharmacists prescribe medicines. There is also the question of anti-biotic resistance which is a major problem. Pharmacists should be allowed to dispense pharmacy only products to medical card patients without prescription. We are all aware that items were removed from the medical card because the Government felt people were getting too many of them. Would the same not happen again?
Before the delegation replies I will take a final question from Deputy Mitchell.
I am concerned about the issue of the derogation and the restrictive practice which appears to be totally against what is happening in every other sector. Is the delegation being unnecessarily alarmist when it says there will be a problem if non-English speaking chemists come to Ireland? To be honest, there is no evidence that it would happen but there are many Irish men and women who would like to come home and start their own pharmacies but cannot do so because of this rule. Is it not inconsistent that doctors but not chemists from the European Union will be allowed to come here without restrictions? Could the concerns of the Irish Pharmaceutical Union not be overcome by a simple language test?
Mr. Feely
There is a worry about health and safety and language tests, etc. However, we have another concern. The Government should be concerned that Irish pharmacists do not have access to other European markets whereas European pharmacists have access to our market. It is extremely unfair that currently anyone can come to Ireland and open a pharmacy, whereas an Irish citizen cannot go and do so in any other member state. If we have a common regulatory system across all member states, our view is that the derogation can go tomorrow morning.
It is unfair, but is it fair that we discriminate against Irish students who have studied pharmacy abroad? How much control do we have over the European Union decision to change that situation? One would be a long time persuading the French and the Germans to agree to these types of changes, but that does not mean they are right.
Mr. Feely
It does not mean they are right. It has to be recognised that it is an issue of equity for Irish pharmacists.
What is the issue for a French pharmacist coming here?
Mr. Feely
The extent of the impact of the derogation is probably overstated. A pharmacist can come to Ireland, buy a pharmacy and set up shop tomorrow morning. He or she can be employed in any pharmacy that is open more than three years. There is no restrictions on them in that area. One of the ironies since the regulations have gone is that young pharmacists are finding it extremely difficult to buy or open pharmacies. The capacity of a young pharmacists to secure finance from a bank to open a pharmacy is extremely limited. The irony is that under the restrictive 1996 regulations - let us be very clear that we are not seeking a return to the 1996 regulations - if one found an outlet, the banks were queuing up to fund it, but that is not now the case.
I accept the validity of the arguments but they are not arguments against getting rid of the derogation.
Mr. Feely
One has to ask the pharmacists who are affected at this point of time. They do not want to see a removal of the derogation because of the iniquitous balance between the European mainland and Ireland. That is coming from a significant number of British educated Irish pharmacists.
They are not the ones writing to me.
On the issue of derogation, a warning tale comes from Norway, where they had a derogation that any pharmacist could set up anywhere. As a result, within 18 months, 80% of the pharmacies are now controlled by three chain operators. Competition is great if there is something to compete against.
Is that what Mr. McManus is saying?
No, I am saying that they have managed to dominate the market and it is very difficult for young pharmacists in Norway to get into the market because two or three big players dominate it. They control the openings and have the best locations. I am all in favour——
However,it is impossible because of this rule.
No, it is not.
Is it possible for Irish pharmacists who are not trained in Ireland to start their own pharmacies?
Irish pharmacists can come here and buy their own pharmacy but they cannot work in it for three years as a result of the derogation, but there is nothing stopping them from——
Would Mr. McManus not consider that a difficulty?
Mr. Feely
I will comment on the issue of a pharmacist who is educated outside the country under the derogation. It comes across that the Irish Pharmaceutical Union made this decision, but it is not our decision. A pharmacist can come to Ireland the day after he or she qualifies and buy a pharmacy, operate it and work in it. They can come to a pharmacy here and work in it. However, the extent of the restriction is that they are not allowed to have a role in a pharmacy that is less than three years old, which in effect means they cannot open a new pharmacy. It does not mean they cannot come to Ireland or cannot buy a pharmacy. The opportunities for new openings for young pharmacists are extremely limited. We are meeting them tonight to talk to them about it and without the assistance currently of wholesalers in the Irish market, young pharmacists would have no opportunities at all.
On behalf of the committee, I thank members of the delegation for attending today and for outlining their concerns about the future provision of services by community pharmacists.
The joint committee adjourned at 11.35 a.m. until 9.30 a.m. on Thursday, 22 April 2004.