Kate O'Connell (Dublin Bay South, Fine Gael) | Oireachtas source

I will. I could spend all day talking about this. I thank the witnesses for coming in. First, regarding formularies, I am sure that everyone on the committee is aware of it but I am a pharmacist by profession. When I worked in the UK approximately 15 years ago, formulary prescribing was standard across the NHS. I was surprised when I came back to Ireland that this was not the case. For example, the particular trust in which I worked made a deal with Wyeth, the company which made Zoton at the time. Everybody who was admitted to the hospital in which I worked, no matter what proton pump inhibitor, PPI, they were on, left on Zoton unless there was contraindications relating to diarrhoea, an intolerance to the drug or so forth. We seem never to have done that in this country. I understand that GPs want autonomy over their prescribing in the same way that pharmacists want a degree of autonomy, but that sort of logic on bulk-buying never seems to have transferred here. That said, it is not all bad. When I came back there were no generics on the market in Ireland and we could not substitute generics. If a doctor such as the Chairman wrote a prescription for Zoton, we had to give Zoton. That has obviously been resolved since.

With regard to formularies and our guidelines, I will move onto Brexit. We all depend on the National Institute for Health and Care Excellence, NICE, guidelines for our prescribing and that may now be taken from us with Brexit. Do the witnesses think that Ireland needs its own group or should there be prescribing guidelines from Europe to govern European countries?

I missed the start of the presentation but I heard very little reference to pharmacists in the contributions. Perhaps I am wrong, but I asked my colleagues on either side of me and they did not hear mention of pharmacists either. It seems bizarre that we would talk about polypharmacy and medicines management without mentioning pharmacists. I was a medicines management pharmacist in the UK and I can read this perfectly. It is very bad, but is a very good example of why we have errors and why we cannot collate data. As Dr. Murphy outlined - and Dr. Harty knows this - the situation is that this comes rattling through on a fax machine. It has probably been crumpled by the person on the far side. This is the practical situation, and people do not know this is going on. Some of the hospitals have the old feeder faxes which have a big crease down the middle. The controlled drugs are not legal because of the way it is written. The pharmacist is then caught. The doctor in the hospital wants to discharge a patient as soon as possible and the pharmacist wants to fix them up. Suddenly it is 7 o'clock in the evening and there is nobody to call about what is written down the crease. It is so unsafe. We have done work on tracking errors, but I would imagine that there are many instances where there are problems for six or seven years because of a crease in the paper or because the wrong person answered the phone.

There is also a huge confidentiality issue when it comes to what doctors, pharmacists, nurses and ward managers have to do with medical records. There has to be an element of trust, otherwise we would find out nothing. One has to hope that the person at the end of the phone is the actual patient or is a doctor. If a malicious person out there wanted to get a person's information they probably could get it. One might wonder why a person would do that, but it is very possible given how the system is set up at the minute. Furthermore, the lack of electronic prescribing and the prevalence of this sort of paperwork means that we cannot collate the data. We are only aware of what goes through the primary care reimbursement service, PCRS. We do not know anything about what is going on with private prescriptions.

Dr. O'Brien said that different areas have different requirements. In my particular area we deal with many patients who require cancer drugs because St. Luke's Hospital is beside us. There are obviously spikes in the data. For example, in areas with high addiction rates there will be issues, or if there are particular pockets of illness in an area.

It was mentioned that GPs are under pressure, and I understand that. The figure of 40% was mentioned. Some people say 35% while others say that it depends on the mix of practice. It is a large amount to be taken from anyone's bottom line. The headroom was not there in general practice. People thought it was, but it clearly was not. It is now a case of getting people in and out as quickly as possible, and that is no way to provide a service. I have long thought that the GP is the key person in people's lives in the community. The rest of us assist people from that base. Without the anchor of a GP and that relationship that people have, things just go unnoticed. That rapport is only built up through consultation, from people being comforted in their time of need. The other stuff can be fixed. It is almost a preventative form of medicine.

I understand where the witnesses are coming from. Do they have any views on the outsourcing duties to other professions? I am talking about nurse prescribers and pharmacists who would deal with things like the contraceptive pill and people who are established on cholesterol medication. These things are fairly standard, and this approach has been taken in some other countries, such as Canada where there have been pilot schemes where pharmacists deal with hypertension management. Vaccinations also work exceptionally well in the community pharmacy setting. We were told at the time that people would be having anaphylactic reactions, and some GP friends of mine asked me how I would cope and suggested that people would be dropping dead.

One in 2 million is the incidence of anaphylaxis to the influenza vaccine. I am not sure if anyone has dropped dead from it in that setting. It is very much risk free and pharmacists have embraced it. At the time, personally, I felt I did not train to inject people and I did not want to do this but we got over it. Like that, can we not train up other health-care professionals in the delivery of other vaccinations? I note the pneumococcal vaccine is out now. Obviously, I am aware vaccinating children is a specialist area and I firmly believe that should be in the GPs' hands.

Also, I see there is a larger role for pharmacists in addiction. We tend to be the profession that often meets people twice a day and because of the nature of pharmacy businesses, the doors are open. This was particularly evident to me during the recent snow when those with addiction, probably, a bit like the women who could not travel to the UK, were the ones who were without necessary medication. A number of us in the Dublin area worked closely together to ensure they were fixed up. Pharmacists in the role of addiction treatment, obviously with specialist training, would take a bit of heat off the GPs.

The Versatis patch is an issue I do not want to go into at length. It is the case that these patches have provided many with really good pain relief but when one has a situation where the total spend in Ireland, at €36 million if we did nothing, was the same as the total spend in the UK - Deputy Durkan asked why that is - I genuinely believe the reason is as simple as that this company just had very good representatives on the road. As a product - they mentioned about non-steroidals in older people with reduced renal function - it was a particularly clean drug. As a prescriber, one could hop it on and one need not worry about this list because it did not interact with anything. It has a huge and convenient role. Also, it left the secondary care setting and arrived in to GPs but those who had to deal with the hassle were the GP and the pharmacist, and the bad news had to be delivered by the GP. I am aware, from talking to colleagues because I am not working in practice anymore, that the letter arrived in September to the pharmacist to say this was happening. Normally, people on stable medication would have three to six months prescriptions and with three month prescriptions this fell right at Christmas to stop people's pain relief. Yet again the doctor had to tell patients they could not have this drug and then the pharmacists in many cases were the ones who were caught in that we knew we were not going to get reimbursed. There was no way around it. The way the HSE handled it was bad and the way GPs and pharmacists were allocated the job of delivering the bad news to those with chronic was quite disrespectful to both professions, which do a great deal for nothing much of the time.

Non-government health-care advertising is something I have seen an emergence of. There is a testosterone advertisement I heard somewhere - I think it was on the radio. This is something I was only aware of in the United States. I would be supportive of the proposal to ban this advertising. I will endeavour to speak to the Minister, Deputy Harris, about this. The witnesses may be aware I am working on a particular piece of legislation to do with the advertising of fake cures or false remedies for cancer at present. This, in some way, is linked with it.

On Versatis, the 15 minutes of paperwork was mentioned. This is also true of the new anticoagulant drugs. I refer to this idea that pharmacists and doctors would have to spend 15 or 20 minutes, and that is in Dublin with broadband. I have heard of people in areas with poor broadband who literally cannot get the form done as the system crashes. When one is a health-care professional, one generally wants to be doing the business of providing health care. One does not want to be filling in forms and justifying why Mrs. Whoever needs whatever.

I understand there have to be guidelines and parameters but when we have shortages, we cannot have skilled people in the medical field filling in forms.

On the total cost of drugs over the past ten or 15 years, since reference pricing came in, it is worth noting that the high-tech drugs are pushing up the total spend. There is this idea that Irish drugs are more expensive than anywhere else in the world. When I qualified, it was about €110 for a box of Lipitor but one can get a box of generic atorvastatin for about a tenner now and that is a blockbuster drug. Many of those drugs came off patent in recent years. However, that slack has been picked up by the high-techs. I feel that is the area we have to really target when it comes to pricing. We are not going to get the atorvastatin any cheaper and even if it came down to €6, it is not going to make any odds. It is the box of whatever high-tech drug that costs a couple of thousand euro. There could be more stringent auditing of these products by the HSE. Sometimes, when supply is restricted until the prescription arrives there is a gap in care, so there are ways of making it better for patients. That said, in the case of the new anti-coagulant drugs, although they are increasing the price of prescribed drugs, there is a knock-on benefit in that we are not going to have people attending Warfarin clinics in hospital. The cost that is being put onto the drugs is coming off outpatients and that has to be recognised. Consequently, people not going into Warfarin clinics and queuing up with snotty noses, coughs and 'flus means the exposure to disease is reduced. The hospital car parks and staff are freed up also. It is not a simple sum - I just wanted to make that point.