JOINT COMMITTEE ON HEALTH AND CHILDREN díospóireacht -
Thursday, 29 Jan 2009

Irish Pharmacy Union.

Chairman

I welcome Ms Liz Hoctor, Mr. Darragh O'Loughlin, Mr. Keith O'Hourihane and Ms Pamela Logan. I draw attention to the fact that, while members of the committee have absolute privilege, the same does not extend to witnesses appearing before it. Members are reminded of the long-standing parliamentary practice to the effect that they should not comment on, criticise or make charges against a person outside the Houses or an official by name or in such a way as to make him or her identifiable.

We appreciate the assistance of the witnesses in our work on the primary care strategy. The purpose of the hearings is to produce a report, which will, hopefully, lend focus and impetus to the implementation of the primary care strategy. The document circulated by the IPU has been useful. Will Ms Hoctor provide a brief executive summary of the presentation before members ask questions?

Ms Liz Hoctor

I am the president of the IPU. I am accompanied by Mr. Darragh O'Loughlin, vice president, Mr. Keith O'Hourihane, chairman of the community pharmacy committee, and Ms Pamela Logan, director of pharmacy services. We are also joined in the public gallery by Mr. Seamus Feely, secretary general, and Ms Kate Healy, press and communications manager. I thank the committee for giving the IPU the opportunity to address it on the subject of primary medical care in the community and to discuss how community pharmacies can deliver on Government health care priorities and achieve true value for money.

People visit their community pharmacy, on average, twice a month. That makes pharmacies the most accessible and visited part of the health service and pharmacists are, therefore, in a unique position to provide an enhanced primary medical care service to people in the community. The primary role of the pharmacist is to improve health outcomes by safely dispensing medicines and advising patients on how to get the optimum benefit from them. Patients do not need an appointment to see their pharmacists and, in addition to dispensing medicines, pharmacists respond to millions of requests for advice from patients each year. In 2007, pharmacists provided 15 million items of advice on minor health problems. However, there is considerable scope to develop the current level of professional services delivered by community pharmacists into a more comprehensive, structured and organised service to the community.

The proposals we made in our written submission of 31 October 2008 are consistent with Government policy such as the Department of Health and Children policy framework for the management of chronic disease and also international policy such as the Tallinn charter. Treating patients in primary care is much more efficient and leads to a better quality of life. One example would be to empower patients in self-management of chronic diseases. Patients visit their pharmacy on average twice a month and that means for patients with such diseases the health care professional they see most frequently is their local community pharmacist who is, therefore, ideally placed to deal with problems as they arise and prevent unnecessary admissions to hospital. This would be done in collaboration with GPs and other health care professional involved in the patients' treatment.

In tougher economic times it makes sense to use an existing resource — community pharmacy — to its maximum potential. The community pharmacy network is an underutilised resource and, if enabled, can provide more services to patients in the community within the primary care setting with a view to keeping patients out of hospital and helping to maintain a good quality of life while living independently in their own communities. That also brings benefits to the Exchequer.

On Monday, the IPU published a review of community pharmacy in Ireland 2007 report. It was produced by PricewaterhouseCoopers and it estimated the advice and services provided by pharmacists to patients across the country in 2007 removed the need for 3.9 million visits to GPs and more than 500,000 accident and emergency department attendances. The estimated value of these pharmacy services, which are not directly remunerated by the Exchequer, is approximately €460 million. Patients need better services and health outcomes and the Government continues to seek better value for money, better adherence to medicines, reduced wastage and improved quality of life by focusing on prevention and early detection of diseases. In this context, the union has advocated the introduction of the following cost saving initiatives for a number of years: the medicines use review; a minor ailments scheme; structured health promotion services; health screening services; and generic substitution.

Patients' needs are evolving and, therefore, we must use existing resources to their maximum potential and the community pharmacy network is an underutilised resource which, if enabled, can provide much needed services to patients in their community. The union recognises the need to maximise efficiencies, particularly in these difficult economic times, and we look forward to engaging with the committee in facilitating the roll-out of health care services through primary care.

However, the HSE outlined to the committee yesterday its view of the development of primary care services in the community. Officials stated it was their aim to provide the public with easier access to the right care in the right place at the right time aiming to provide 90% of care within their communities or homes. We fully support that strategy but we have strong reservations about their approach to the implementation of these services, as there seems to be much focus on the provision of buildings rather than on the co-ordination of services across the wider community health care network, which are focused on meeting the needs of the patients. I ask the committee to consider this issue in coming to conclusions on the matter. We are happy to answer questions members may have on our submission.

Deputy James Reilly

The last point is an interesting one because, as others see it, no buildings have been built and the emphasis is on reallocating staff. Yesterday, the HSE informed us there would be no additional resources for new staff, but that it would reallocate staff from within. Subsequently, the Irish Physiotherapy Society was before the committee and it informed us that 59% of its graduates last year were unemployed and there was a 16 to 52 week wait for physiotherapy services. Therefore, I must take issue with what has just been said.

I agree we need new buildings and proper infrastructure. Some of the areas in which people are working are below standard. We need to move on to a situation where primary care will be seen as a real alternative to going to hospital and where people will be confident that the building will be bright, clean, efficient and staffed with the necessary personnel to allow them receive in the community the full range of treatment they require rather than having to go to hospital just to be given a diagnosis — which is currently the case. The aim is that this should be available in primary care.

What would the Irish Pharmacy Union wish to see happen with regard to the future development of primary care?

Deputy Jan O’Sullivan

I welcome the delegation. On the same point, it was implied by the delegation that pharmacy premises could be more widely utilised. Should a pharmacy be included in these primary care team buildings which, according to what the HSE told the committee yesterday, is the optimum arrangement — one centre for all the elements of the primary care team?

I refer to the Irish Pharmacy Union's views on wastage in the system and inappropriate use by patients of medication or medication being thrown away or people taking unnecessary medication. The delegation suggests that quite an amount of money could be saved in that area. I ask the delegation to expand on this point.

I refer to substitution of generic drugs which according to the delegation works well in other countries where pharmacists are allowed to substitute a generic drug for the prescribed medication. Is legislation required for this practice or can it be allowed by regulation? How could this practice be implemented in Ireland?

Deputy Margaret Conlon

I welcome the members of the IPU, the Irish Pharmacy Union, to the meeting. The community pharmacist has a significant role to play in the delivery of primary care and in a primary care team. For many people, particularly those who are not in the general medical scheme, the first port of call is their tried and trusted pharmacist. They have a chat and they may be able to buy something over the counter that might cure their ailment and, if not, they will then go to the GP. This highlights the significant role of the pharmacist. The development of services within pharmacies would be welcomed by many people.

To follow on from the points made by Deputy Jan O'Sullivan about wastage, there is greater scope for information and public awareness campaigns to highlight the importance of taking prescribed medication properly. Some people are very reluctant to take their medicine properly. For instance, if the prescribed dose is one four times a day and they forget a dose they then take three all together and this has its own consequences. A lot more could be done to encourage people to take medication sensibly.

A few years ago when an elderly neighbour of mine died, I helped to clear out the house. I was horrified at the number of bottles of medication found in a cupboard, some of them unused. As this person had been a GMS patient and was given a prescription every month, she collected the medication every month and did not use them. It is necessary to dispose of medication properly. The other awareness campaign which is important and necessary is to do with self-prescribing. People now have access to the Internet and other ways of acquiring medication and self-prescribing poses risks and dangers. There is a need to inform and educate in the area of health promotion and information and pharmacists are central to this strategy.

With regard to substitution by generic drugs, we are now in very difficult circumstances and people are looking for better value for their money and their limited income. In certain circumstances there is a case to be made for allowing pharmacists to substitute medication, to make medication more affordable for people and I ask the delegation for its views on this subject.

Deputy Rory O’Hanlon

I thank members of the IPU for their presentation and in particular for the documentation they have sent to the committee. I appreciate very much the contribution pharmacists make to communities, particularly in rural Ireland, where they know their customers personally.

There is an opportunity in the development of primary care to give an enhanced role to pharmacists within the community care team. I would like to see this being developed.

I ask the delegation to elaborate on two of the various cost-saving initiatives referred to in the submission. One is the medicines use review and the question of compliance and waste. I am concerned about compliance because many patients do not complete the course of medicine necessary for them and the other more dangerous practice is that patients sometimes share their medicines with their neighbours and this might not always be in the best interest of the neighbour. How does the delegation envisage the medicines review being carried out by the primary care team?

I have always held the view that there is an obligation on doctors to use generic products provided they are satisfied those products will do the particular job. Many years ago, when I was practising, there was a difficulty with bio-availability and one had to be careful, but we are past that time now. It is important that a GP as the prescriber should be satisfied that what is being prescribed is efficient to do the job.

I am all in favour of generic substitution. The delegation named ten countries within the EU where this is the practice. I ask the delegation to send the committee some further information on how those countries operate this practice. In terms of allowing pharmacists in Ireland to substitute, would the pharmacist consult with the doctor or is there a role for the local medical and pharmaceutical professions to agree on the particular substitutes that would be acceptable to the prescriber and so give the pharmacist a free hand to dispense generic medicines rather than proprietary brands? There would be some form of agreement with the GPs to ensure they would be satisfied as to the efficiency of the product. This does not just apply to the local pharmacists, but also to the multiplicity of prescriptions that come out of hospital, very often written by junior hospital doctors and posing a dilemma for the GP who has to take responsibility for them.

Deputy Charlie O’Connor

I welcome the delegation. I may have to be unusually parochial for a moment in order to make a point. I live in an estate in Tallaght with approximately 2,000 houses and on which there are three pharmacies, all of which are thriving, about which I am pleased. I try to visit them regularly. I refer to what the president of the IPU said and the attitude of the HSE. In my immediate community we have been campaigning for the HSE to set up and fund a primary care team and seem to be making progress. They are now talking about buildings which I know is another matter for debate. My community includes more than 800 local authority houses, the residents of which which have no doctor or pharmacist in the immediate vicinity. There is a clear need for a strong partnership link between pharmacists, the local hospital which is located close by — I will not say it is within a stone's throw — and the HSE in terms of its primary care ambitions. Deputy Reilly made a political point at the beginning of his contribution but we should take the opportunity to say to the IPU that there is a clear role for its members to play in delivering services to local people. That is the point I wish to emphasise.

Ms Liz Hoctor

Deputies have raised some interesting points. I will begin with Deputy Reilly's questions. He asked what was the one element the IPU wished to see in primary care services. It would be a structured minor ailments scheme based in the community. Allied with this, we should have a structured primary care chronic disease management programme because many patients with chronic diseases live in the community and are not hospital inpatients. We need clear communication between all members of the health care network. For example, it is essential that a patient with diabetes who presents with a sore foot be immediately referred back to his or her doctor or chiropodist. All that is required for this to happen is clear communication lines between the members of the primary health care network. The IPU asks that this be one of the recommendations of the committee.

Deputy O'Sullivan asked some very interesting questions about pharmacy premises. Apart from the fact that more services could be accessed through such services, it is also a case of accessing the expertise of the pharmacist. Deputy Reilly has said the HSE stated at the meeting yesterday that it lacked enough staff. Pharmacists are well educated health care professionals who have the ability to deliver more services, in particular in dealing with minor ailments and in chronic disease management. Mr. Darragh O'Loughlin will expand on this point.

Deputy O'Sullivan also raised the issue of generic drug substitution and whether this required legislation. Pharmacists cannot legally substitute generic medicines for a proprietary or brand name medication. A clause in the agreement made between the Government and the manufacturers stipulates that pharmacists must dispense what is written on the prescription. As Deputy O'Hanlon said, there are no longer any concerns about a technical term he used, bio-equivalents. We know that the generic medicine is exactly the same as the proprietary medicine and where it is safe and appropriate, the pharmacist should be able to substitute. This would certainly lead to savings for the State and also, as Deputy Conlon said, private patients.

Deputy Jan O’Sullivan

Would legislation be required?

Ms Liz Hoctor

Yes, legislation would be required. Mr. O'Loughlin is the expert in this area. He informs me it could be changed under regulations to permit pharmacists to dispense generics. Ms Logan can provide the information requested by Deputy O'Hanlon. We ask the committee to make a recommendation that pharmacists be empowered to substitute generic medicines where it is safe and appropriate to do so.

Deputy Conlon stated pharmacists were the first port of call and that more services should be delivered through pharmacies. The HSE health care campaign used the slogan, "Use the right door". For most patients, especially in tough economic times, the first door is that of their local pharmacist, with whom they have a relationship. We ask the committee to make a recommendation on the need for structured health promotion services to allow patients to know how they can access services in their community.

Deputy O'Hanlon asked about the medicines use review, as well as compliance and wastage. He also raised the question of generic substitution.

Deputy O'Connor raised the question of the links between primary and secondary care. The pharmacist is the one person who always knows when a patient has been referred for secondary care treatment. A patient may attend multiple outpatient clinics but often the only person who knows about all the visits a patient makes is the pharmacist because he or she is the person who sees all the prescriptions and therefore the one person with a complete record of all the medications prescribed. It is very important to have links within the primary care network.

I ask Mr. O'Loughlin to comment on the other points raised, to be followed by Mr. O'Hourihane and Ms Logan.

Mr. Darragh O’Loughlin

I will begin with the questions asked by Deputy Reilly. We are not opposed in principle to primary care buildings but sometimes it seems as if the focus is on providing the building and that there is no focus on the patient. We need to think more about the patient and the services needed by patients in their communities. As they need those services now, we need to start providing the services and the buildings will follow. However, we cannot wait for the HSE to build the mega-centres around the country because, as the Deputy pointed out, they are not happening and the services need to be provided now. That is the reason the focus needs to be put on patients and services.

The Deputy asked what was the one element we would like to see. Ms Hoctor mentioned the chain from minor ailments through to chronic disease management. At a seminar last Monday in Dublin a pharmacist from an organisation called Kaiser Permanente in the United States — the organisation which owns the hospital in which the octuplets were born on Monday and which suddenly made it world famous. It runs a chronic disease management service through its pharmacies. It is a HMO which owns hospitals and pharmacies and has primary care physicians. It has found that by using pharmacists to adjust the dosage of medications prescribed for patients by GPs in the case of cardiac illness, diabetes, anti-clotting drugs such as warfarin, by titrating or adjusting them within parameters set down by the doctor, it has actually led to a decrease in mortality and morbidity by 75% to 90%, depending on the condition, simply because patients are being monitored far more frequently. As Ms Hoctor said, patients are willing to come to a pharmacy once a fortnight but no patient will go to a doctor or an outpatients department that frequently. The pharmacist, patient and doctor work almost as a team on a collaborative basis to monitor and adjust the patient's therapy. As a result, the outcome is optimised for the patient without imposing an extra drain or demand on the resources of the HSE or hospital sector.

The minor ailments scheme works by providing the same level of service for medical card patients in a pharmacy as that available to a private patient. We should be able to give non-prescription medicines, where appropriate, to medical card patients without them having to go to their GP for a prescription, which adds time and delay and is a drain on the GP resource. By and large, the GP does not want to have to spend time writing prescriptions for paracetamol when someone has a headache or for lice treatments because every mother can diagnose a lice infestation in her own child's hair. It is a waste of resources which we need to use more effectively, as we do not have the money we used to have. A minor ailments scheme would allow us to do this.

Deputy O'Sullivan asked whether primary care centres ought to have pharmacies located within them. We say they should not be located there. The Pharmacy Act 2007 which was passed unanimously by both Houses of the Oireachtas and which was endorsed by the committee also agreed that the centres should not contain pharmacies because there must be a clear economic break in the link between prescribing and dispensing medicine. The last thing anyone needs is a situation where patients have a worry or fear that the medication is being prescribed for the economic benefit of either the pharmacist or the medical centre, not necessarily the health of the patient. In other countries all the evidence points to the need to have a clear break between prescribing and dispensing, which is the reason the Government and the Oireachtas inserted the relevant sections in the Pharmacy Act which prohibit such links. The IPU endorses this action and hopes the sections will be commenced and enforced immediately, with the rest of the provisions of the Act.

There has been much talk about information for patients and patients not being equipped with the tools they need to optimise the benefits from their own medicine. The structured medicine use reviews we have talked about involve a one-to-one consultation where the pharmacist is allowed to make time to sit down for 15 or 20 minutes, or whatever time it takes, with a patient — usually an elderly patient or someone who might be on five, six, seven or more medications. I know the two general practitioners present will be very familiar with this patient cohort. Such a patient requires considerable care and time to ensure he or she knows what each medication is for, knows how to take it and knows what side effects might be involved. The pharmacists can monitor whether they are taking the medication.

Deputy Conlon said that she found bottles of medication that a patient had not been taking. She obviously had not told her GP she was not taking the medicine. It may often be that a particular blood pressure tablet might make her feel tired or dizzy or another tablet might make her feel nauseous. She might not feel the benefit of her blood pressure reducing but may feel sick or tired. She will not tell her doctor because she is somewhat shy about admitting she is not taking it. We need to get behind the reasons for patients not to take their medicine and ensure they take the minimum dose that will do the job, thereby avoiding side effects. We need to ensure they understand whatever side effects they may have.

We would recommend that the primary care structure needs to have a structured medication use review system put in place for patients, as is done in the UK and Australia where they have found it saves money because only the medications that are necessary are used. It improves patient outcomes because they are getting the benefit from the medication the doctor has prescribed rather than hoarding medications at home. It also reduces self-harm. We need structured planned medication use reviews where the pharmacist and the GP collaborate in the care of the patient.

Mr. Keith O'Hourihane

Deputy O'Connor mentioned, as did Mr. O'Loughlin, that when a person dies, a lot of medicines are left. Pharmacies, in association with the union, have managed to put together some health promotion campaigns. It would be excellent for us if these were structured and co-ordinated with other health care professionals. The most recent one we did concerned antibiotic awareness. That was done in conjunction with the Department of Health and Children, the Health Service Executive and pharmacists, and reached the majority of the population. We were in a position to advise people when it is appropriate to take antibiotics.

We were hit by an unusual virus and flu this year. Pharmacies were inundated with people with upper respiratory infections. It is also very important for us to tell people when it is not appropriate to take antibiotics and not to clog up general practitioner surgeries. However, we do not want people simply to take over-the-counter treatments, including cough bottles, on an ongoing basis and then to become a problem. Health promotion puts pharmacies in a position to assist patients. We would very much like the opportunity to have structured health promotion and to see that occurring on an ongoing basis.

With regard to medicines that are not being used and being found in people's homes after their deaths, there have been ad hoc disposal campaigns. It would be great if there was an ongoing campaign.

Deputy O'Connor said that the pharmacy is integrated in his community and his constituents and our patients find it a great resource. It would be excellent if we could harness that. The World Health Organisation stated yesterday that we are poor in maintaining tobacco control and that a number of people are still smoking even with smoking bans, etc. It would be great to have a national programme. Pharmacists have the opportunity to intervene with people when they come for cough bottles or other over-the-counter preparations. We, as professionals, may ask them if they smoke and why they smoke. We can point out that their smoking is not helping their ailments. There is not a structured anti-smoking campaign on which we can bring people along. The Health Service Executive has smoking cessation officers. Putting together a promotion campaign that would reduce the incidence of smoking obviously would assist us. In Finland asthma promotion has been very successful. There pharmacists have been given the opportunity to counsel people on simple things such as how to insert an inhaler in the mouth and use it properly. It has shown that the control of the asthma has been excellent.

We would like the committee to empower us to be involved in integrated health promotion strategies similar to the antibiotic awareness campaign that we have found to be very successful and useful.

Chairman

Mr. O'Hourihane is effectively saying that the primary health care team would be a local health promotion team in every sense.

Ms Liz Hoctor

We will be asking that a recommendation be made that the pharmacist in the primary care network would take part fully in structured health care promotion.

Chairman

Is it the network, which we understand to be the regional organisation or the local primary health care team?

Ms Liz Hoctor

In the original primary health care strategy the pharmacist was seen to be part of the wider health care network as opposed to being within the primary health care team. That is because pharmacists are very accessible given their locations dispersed through the communities. That ties in with the fact that as a union, we are hoping to encourage our members to roll out screening for risk factors resulting in the early detection of chronic diseases. Ms Logan is head of our pharmacy services unit. I might ask her to speak about that.

Chairman

This is certainly an area of confusion. Our very clear understanding to date has been that the pharmacist was an essential part of the local primary health care team and that the network was at a level above that, working more on a regional basis. I believe the document refers to a population base of 30,000 to 40,000 people. However, the primary health care team would serve a population of 8,000 to 10,000 people.

Mr. Darragh O’Loughlin

Pharmacists and dentists, for example, are considered part of the network because the pharmacist does not work solely to one general practitioner's practice.

Chairman

We fully appreciate that.

Mr. Darragh O’Loughlin

The original strategy did not envisage pharmacists as being part of that core team because the pharmacist needs to work collaboratively with every GP practice in his or her area.

Chairman

That clarifies that.

Deputy Charlie O’Connor

What engagement does the union have directly with the Health Service Executive on this important issue?

Chairman

What engagement has it had to date on this matter?

Ms Liz Hoctor

We have made a submission to this committee on it.

Chairman

Has the Irish Pharmacy Union had any engagement with the Health Service Executive?

Ms Liz Hoctor

No. There has not been any official engagement with the HSE. We have made submissions and worked collaboratively with it on health care promotion. However, that was on an ad hoc basis rather than on a structured basis. That is why we ask that the committee make a recommendation that pharmacists should be seen as part of the structured health promotion campaigns it might run.

Chairman

That is very helpful. Does Ms Logan wish to add something?

Ms Pamela Logan

I will fill in a few points made by my colleagues. Deputies O'Sullivan and Conlon referred to awareness campaigns and issues relating to compliance and wastage. These were recommendations of the adverse side effects committee which highlighted the need for awareness among the population about compliance with medicines. It is estimated that 50% of people with chronic diseases do not take their medicines properly. Deputy Conlon referred to the issues with wastage. We certainly need to have some more structured campaigns to deal with those issues. That can be dealt with through medicines reviews, dump campaigns and health promotion.

Deputies Conlon and O'Hanlon referred to generic substitution. The IPU made a submission to the HSE a few years ago. I can supply that to the committee, as it will give members details of the various countries that do it and how they do it. Deputy O'Hanlon asked about the pharmacist and general practitioner consorting over which ones could be substituted or not. Typically in most European countries that allow generic substitution, there is a box in the prescription that the doctor can mark if he or she does not want the product substituted, which should address that issue.

Deputy O'Connor referred to the very important issue of ensuring a strong link between hospitals, GPs and pharmacists. Many adverse events occur on the discharge of patients from hospital into the community and vice versa. Much of it is due to not having an electronic patient health record or communication links between them. The HSE has been working on an integrated discharge planning protocol which, if implemented, should address some of those issues. One of our community pharmacists recently carried out a masters thesis on prescriptions moving from secondary care into primary care. One third of prescriptions had errors on them, which leads to great potential for people ending up back in hospital with consequent costs back in secondary care.

Chairman

As we are running over time, are there any brief supplementary questions?

Deputy James Reilly

It is important to point out that it is a matter of services and buildings — they go hand in hand — rather than services or buildings. It is difficult to deliver services when there is no building in which to deliver them. Many surgeries and health centres are not of a sufficient standard. It is not a question of one or the other. We are very much in favour of the right substitute generic drugs. As a fellow general practitioner, I agree with Deputy O'Hanlon, who has expressed concerns about the prescription of generic medication to deal with chronic conditions such as high blood pressure. An important aspect of the compliance safety system is the need to ensure that patients can recognise their medication. There may be mayhem and confusion if the box changes every three months when a new cheaper generic product comes on the market. It could contribute to ill health.

I would like to leave an interesting observation hanging in the air. The IPU has said it does not want pharmacies to be located in the same buildings as primary care providers. It has cited the potential for conflict if there is a relationship between those who dispense and those who prescribe as the reason for that. However, both parties are often quite happy to prescribe and dispense for minor ailments. In an ideal world, the HSE would own those buildings. Everybody in them would be a tenant. They would have no relationship with each other, other than through the HSE. Under such circumstances, I cannot see any reason health service providers would not want to be in the same centre, in the interests of patients' convenience. That will be a reality in the future, as practices amalgamate. That is what we ultimately want to see, regardless of what pharmacists want to do in terms of staying outside that. There is some merit in the point that has been made about dispensing medication in the community, so that people can communicate.

As others have said, the compliance of pharmacies is of huge value. Does the IPU have any ideas on the issue of chronic illness schemes?

Chairman

I hope this is the Deputy's final question.

Deputy James Reilly

I will make a final statement about the minor ailment scheme. I think it will be a valuable part of the system.

Chairman

I ask Ms Hoctor to respond briefly. If we need to get clarification from her in respect of other matters, we will correspond with the IPU. I am conscious of the need to allow other groups to make presentations.

Ms Liz Hoctor

I will respond quickly. Deputy Reilly spoke about the location of pharmacies within health centres. There is evidence in our near neighbour, the UK, of what happens when pharmacies are located in health centres. In such circumstances, all the other pharmacies in the town tend to relocate to the vicinity of the health centre in question. If a reasonable number of pharmacies are not dispersed around the community, it is more difficult for patients, who are the main subject of primary care strategies, to access services. In the UK, the NHS had to deliver ancillary services on the high street — in other words, it was duplicating the service that was already being provided. The message we want to transmit at today's meeting is that the pharmacy sector is an underutilised resource. If we want to achieve the outcomes that patients deserve in these tough economic times, we need to make the best use of the existing community pharmacy resource.

Chairman

I thank Ms Hoctor. The IPU's point is clear. All the members are happy. I thank the IPU for its presentation. I suspect that the committee will be corresponding with it.