Michael Harty (Clare, Independent)
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This morning we are meeting with representatives from the Irish College of General Practitioners, ICGP, the Royal College of Physicians of Ireland, RCPI, and the Royal College of Surgeons in Ireland, RCSI, to discuss the issue of prescription patterns, the monitoring and auditing of the use of drugs and the effect of trends in prescribing medications. On behalf of the committee, I welcome Dr. Mark Murphy and Dr. John O'Brien from the ICGP, Professor Mary Horgan from the RCPI and Professor Tom Fahey from the RCSI.

I draw the witnesses' attention to the fact that by virtue of section 17(2)(l) of the Defamation Act 2009, they are protected by absolute privilege in respect of their evidence to the committee. However, if they are directed by the committee to cease giving evidence on a particular matter and they continue to do so, they are thereafter only entitled to qualified privilege in respect of their evidence. They are directed that only evidence connected with the subject matter of these proceedings is to be given and they are asked to respect the parliamentary practice to the effect that, where possible, they should not criticise or make charges against any person or entity by name or in such a way as to make him, her or it identifiable.

I also advise the witnesses that any opening statements they have made to the committee may be published on the committee's website after this meeting.

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 will now accept the opening statements, starting with Professor Tom Fahey.

Professor Tom Fahey:

I thank the committee for inviting me. To provide the committee with some background, I am a clinically and research-active GP who trained in epidemiology and public health. I have been based in the UK for 14 years, working in Oxford, Bristol and latterly Dundee. Since returning to the RCSI in 2006, I have led the Centre for Primary Care Research, which is nationally funded by the Health Research Board, HRB. To give the committee a brief idea of what we have done in that time, our research group is active in the area of prescription medicines and drug safety. We work with colleagues in the school of pharmacy in Queen's University Belfast, and this has enabled us to examine the quality and safety of prescribing in Ireland both North and South and to benchmark Irish prescribing practice to other countries.

The current challenges in Ireland are that prescribing in many hospitals remains a paper-based activity; communication regarding medication for patients between hospitals, general practice and pharmacy is also predominantly paper-based. This means that transcription, dosage and monitoring errors are more common and patients are at greater risk of adverse drug events. Electronic prescribing and dispensing are the standard in general practice and pharmacy practice, but electronic prescribing and dispensing systems do not interact effectively, meaning the process of prescribing and dispensing is disjointed and poorly integrated across the health sectors. Lastly, access to prescribing data for research, education and quality improvement purposes is very limited in Ireland. The solution to all these issues is to develop an e-prescribing platform in Ireland with appropriate training and education for all health professionals involved in prescribing. Enhanced transparency in respect of prescribing practice will enable a culture of professional reflection and engagement with nationally established quality improvement initiatives, such as the medicines management programme.

Michael Harty (Clare, Independent)
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I thank Professor Fahey. I now call Professor Mary Horgan.

Professor Mary Horgan:

The Royal College of Physicians of Ireland welcomes the opportunity to inform the committee about the work in which it is involved to ensure safe prescribing.

The RCPI is Ireland’s largest postgraduate medical training body, with more than 11,000 trainees, members, fellows and licentiates working at home and abroad. The college is committed to helping doctors to enhance their skills, competencies and professionalism throughout their working lives. The RCPI includes six of the 13 postgraduate medical training bodies, including the faculty of occupational medicine, the faculty of paediatrics, the faculty of pathology, the faculty of public health medicine, the Institute of Obstetricians and Gynaecologists and the Irish committee on higher medical training, which includes medicine. It also has two joint faculties, namely, the joint faculty of intensive care medicine of Ireland with the College of Anaesthetists of Ireland and the Royal College of Surgeons in Ireland and the faculty of sports and exercise medicine, which is a joint faculty with the RCSI. The college also provides lifelong learning and continuous professional development for members and allied health care professionals. The RCPI leads 20 ground-breaking national clinical programmes in conjunction with the HSE that are helping to transform health care in Ireland. The college is also a passionate advocate to improve the health of the nation.

As for medical training and education, the prescribing of medicines is a fundamental part of the interaction between doctors and patients and is an integral part of the postgraduate medical training programmes and continuous professional development courses provided by the RCPI. Every year, the RCPI delivers over 200 courses to approximately 7,000 participants to equip health care professionals with the skills to meet the demands of a rapidly evolving society. As a college, our objective is to deliver world-class specialist training to the 1,200 doctors in our basic and higher postgraduate medical training programmes across all the specialties alluded to above, which are in the main delivered in hospitals across Ireland. As these trainees are responsible for a substantial amount of prescriptions given to patients in hospitals, it is fundamental that they are equipped with the knowledge and skills to do this safely and effectively. All of our courses on safe prescribing are mandatory for doctors in our basic specialist training programmes, which is a programme just after intern year. They include awareness of prescription pattern monitoring and the audit of usage and effectiveness trends for prescribed medications and the economics of prescribing. All the doctors who come to the RCPI already will have some knowledge of prescribing as it falls within the remit of undergraduate medical schools. As I have just completed a term as dean of the medical school in University College Cork, UCC, I am aware of this.

In our basic specialist training programmes, safe prescribing is embedded in our curriculum and focuses on prescribing in various medical speciality areas such as obstetrics and gynaecology, general internal medicine and paediatrics. We also deliver a clinical pharmacology training programme for a small number of specialist doctors at a higher level. Our courses are designed to support doctors to prescribe the right dose of the right drug for the right diagnosis to the right patient at the right time. Trainees learn about the elements of safe and appropriate prescribing, adverse drug reactions and to how report them to the Health Products Regulatory Authority, HPRA, risk management and legislation related to prescribing in Ireland. A mandatory course has also been developed for doctors in haematology and oncology that covers the essentials of chemotherapy. Doctors learn about the essentials of chemotherapy, including classification of chemotherapeutic agents, the principles of chemotherapy, standards and the mechanics of chemotherapy and common supportive medications, pharmaeconomics, which is very important, and drug access. In addition to safe prescribing, trainees are taught to help to combat the rise of antibiotic-resistant bacterial infections. I am an infectious disease physician and this is a particularly challenging area of our job in hospital-based medicine.

Antibiotics are the most commonly prescribed drugs and our course outlines the general principles regarding antibiotic prescribing, the mechanism of action and spectrum of activity of commonly prescribed antibiotic, the rates of antibiotic resistance in Ireland and key aspects relating to antibiotic stewardship. This online course is approved by the national hospital antibiotic stewardship committee. Value for money and efficiencies are addressed through an online introduction to the health economics landscape in Ireland that focuses on health service funding models, equity, cost effectiveness analysis and health technology assessments. These courses have all recently been reviewed and updated and are generally updated every three to five years. RCPI is committed to providing world class postgraduate medical training and education for the next generation of specialists and will continue to explore how to enhance this experience in all areas, including prescribing of medicine.

Michael Harty (Clare, Independent)
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I thank Professor Horgan. Next is the opening statement from the Irish College of General Practitioners, ICGP.

Dr. Mark Murphy:

I thank the Chairman and members of the committee for their invitation to the ICGP to discuss prescription pattern monitoring and the audit of usage and effectiveness trends for prescribed medications. We intend to split our five minute opening statement into several sections and I will begin.

To provide some context, there is a rising prevalence of chronic diseases and multi-morbidity in Irish society and while this is not currently reflected in the new GP contract, we hope that it will be soon. This increased prevalence coupled with the fact that we have an ageing population means that we have seen a rise in the number of dispensed items and in the cost of medications in the annual health budget. Our submission outlines in detail the expenditure on pharmaceutical products but in summary, we spend approximately €2 billion on pharmaceutical products per year. That money comes exclusively from the community budget, even if the product is prescribed in a hospital setting. In contrast to our drug budget, Irish general practice is extremely poorly resourced. We spend less than 4.5% of our overall health care budget on general practice. At a time when GP led, community oriented health care should have happened, we have seen a massive retraction in GP funding and in the time we have with each patient. The FEMPI cuts are still imposed on general practice, which limits time for patient care. We work off a 40 year old contract and have severe capacity restraints, with the lowest number of GPs per head of population in Europe. We are also seeing an exodus of our GP graduates.

I will now provide some context for how repeat prescribing works. In the context of acute consultations, it is estimated that two out of every three will result in an acute prescription but GPs manage the repeat prescribing. All of the repeat prescriptions that are issued in pharmacies are delivered by GPs. We might issue a repeat script every three to six months but this can be more frequent if there is a clinical need. While the GP takes the responsibility and assumes the risk for repeat prescribing, the GP may not have been the original prescribing doctor. If a drug is initiated in hospital, the GP transcribes that prescription to a GMS script for a GMS eligible patient.

The ICGP supports evidence based and cost effective treatments in the Irish health care setting, including prescriptions. The ICGP also supports initiatives from the medicines management programme to support effective prescribing. Opportunity costs are evident throughout the health care system, whereby we spend money on low value products with limited benefit and excessive costs which results in other areas of our public health care system being under funded.

Finally, with respect to evidence of trends, from a general perspective raw data from the annual Primary Care Reimbursement Service, PCRS, statistical analysis is very helpful but we must remember that it is raw. I point committee members to the work of the department of general practice staff of the Royal College of Surgeons, where I also work. Professor Tom Fahey and Dr. Frank Moriarty have published research in this area which shows that from 1997 to 2012, there has been a massive increase in prescribing. The prescribing of ten or more drugs for over 65s in 1997 stood at 2% but by 2012 this had increased to 22%. Prescribing has increased massively and we must ask if this is appropriate. The Health Research Board has examined this and found that the odds of what is called "potentially inappropriate" prescribing in 2012 compared to 1997 have reduced by 60%.

GPs and hospitals are prescribing more medications for an ageing, more complex and more multimorbid population but they are doing a better job at it. Our submission also outlines valuable research from other cohort studies, such as the Irish longitudinal study on ageing. That has shown that we can save more than €150 million each year if we introduce a system of reference pricing.

Finally, I will address the prescription of benzodiazepines, anti-depressants, opioids and antibiotics. These are high-profile, topical drugs. We can discuss this in the questions-and-answers session but I will discuss anti-depressants as an example. In 2016, we spent more than €40 million on anti-depressants. To put that in context, we spent only €10 million on counselling in primary care. All evidence suggests that GPs are prescribing very appropriately in the context of a severe capacity shortage in general practice and primary care. Our prescribing of anti-depressants largely reflects a lack of psychological therapies and a lack of social therapies to deal with issues including isolation, fragmented communities and austerity.

Dr. John O'Brien:

What can we do about it? It is pivotal that GPs are provided with sufficient time and resources to enable shared discussion on medicines management. We need to address the challenge of medicines reconciliation across health interfaces and promote electronic discharges to reduce error and improve quality. The role of clinical pharmacists in the general practice team or in a nursing home setting should be explored albeit as part of a new GP contract. Monitoring and audit of prescribing, if done correctly, has the potential to be an extremely powerful tool for GPs in their ongoing efforts to deliver the very best care for their patients.

Research and audit needs to be actively supported and promoted at the highest level. We need to be careful when comparing raw prescribing data from individuals with national standards. We need to take account of confounders such as poverty and deprivation or conditions such as multimorbidity and depression. Continuous medical education has seen a curtailment in funding in recent years and this needs to be reversed. Pharmaceutical advertising in the national media indirectly promoting certain products has been an unwelcome development in recent years. This should come under legislative control, as GPs are encountering demand for drugs and services which have dubious cost-benefit. This committee should endorse a recommendation for a ban on non-governmental health care advertising, especially the indirect promotion of drugs in the media.

GPs need time to deal with complex cases. This will require a modern GP contract that facilitates the management of chronic conditions and medication management. Before this, there is need for the urgent reversal of the financial emergency measures in the public interest, FEMPI, provisions, which have curtailed the ability of general practices to grow at a time when GP services should be expanding in the light of multimorbidity, ageing and increased numbers. We also need to retain our brightest and best GPs. Some 20% leave the country. They see other health care systems as a preferable career option. The ICGP is becoming increasingly frustrated with the lack of Government action on these key matters.

We need to direct any savings that we make in drug prescribing back into general practice to reinforce a cycle that is to the benefit of the patient and of the health system more widely. A medicines management programme, led by GPs, needs to be created as part of the new contract. The ICGP is willing to continue to work and collaborate with the HSE and educational bodies to promote cost-effective, evidence-based prescribing. Sometimes collaboration has not happened. An example would be online ratification for the issuing of certain drugs, which is time-consuming and often quite complicated. This has disenfranchised and increased frustration among GPs as they try to deliver care. Prescribing trends can only be identified through research and audit. Academic career structures for GPs have not been sufficiently facilitated by the HSE or the Department of Health.

Similarly, research on our electronic health records is underdeveloped in the Irish setting - I refer, for example, to the research done through the Irish Primary Care Research Network, which is run through the ICGP - and will require expansion and State funding in order to deliver savings in the future.

Michael Harty (Clare, Independent)
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I thank Dr. O'Brien. The attention of this committee was drawn to this issue in recent weeks by media reports suggesting that the medical profession is over-prescribing medication. That is why we have asked the witnesses to attend this morning's meeting. We will take questions from three members at a time. I ask the witnesses to note the questions that are asked and we will come to them after the third speaker. The first three members I will call are Senator Colm Burke and Deputies Margaret Murphy O'Mahony and Louise O'Reilly.

Colm Burke (Fine Gael)
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I thank those who have presented here this morning for the work they are doing. We appreciate their commitment to trying to improve the health care sector. As the Chairman has outlined, we decided to look at the increase in the prescribing of drugs on foot of media coverage of the issue. According to the paper submitted by Professor Fahey, the percentage of people over the age of 65 to whom five or more medicines are prescribed has increased from 17.8% to 60.4% and the percentage of people in this older cohort to whom ten or more medicines are prescribed has increased from 1.5% to 21.9%. I wonder how this country compares with other countries in this regard. Are comparisons available? Can what has occurred in this country in this area be compared with what has occurred in other countries in this area?

I know there have been huge demographic changes in Ireland. People are living longer. Life expectancy has increased by 2.5 years since 2000. This means we have more people over the age of 65. The number of such people will continue to increase. I am sure the witnesses have looked at the changes in demographics we will face over the next 12 years. How can we best deal with this issue? If we have more people over the age of 65, will we have an increased level of demand for medications and will costs continue to increase? The cost of medication has increased dramatically over the past ten or 15 years. I think the annual cost of pharmaceuticals was approximately €570 million in 2000, but now it is slightly over €2 billion. When there is such a substantial increase, other areas like GP funding lose out. I agree with the witnesses that the whole GP contract needs to be reformed. That needs to be fast-tracked. I have been one of the people looking for that.

The second issue I want to raise is electronic prescribing, which is used very effectively in other countries. Sample prescriptions have been given to us today. If we tried in the morning to set a target for the introduction of electronic prescribing across GPs, hospitals and pharmacies, and if the necessary funding were provided, what kind of timescale would be required for the introduction of such a system? Should we be setting targets to be achieved? My concern about health care is that we seem to be doing budgets on a year-to-year basis without also doing long-term planning. We have lost out in the whole area of electronic records. Someone who goes to three different hospitals will have three different files. The same point can be made with regard to prescribing. I wonder whether we can set targets and, if so, what kind of timescale would be required for us to implement those targets.

My final point relates to the substantial increase in the number of people applying for GP training this year. There has been a slight increase in the number of places, but this has not been substantial enough. Do the witnesses believe we can reverse the exodus of GPs out of the Irish system? If a new contract is offered, obviously it has to be attractive.

Will Ireland still compete on the world market? This is one of the problems we are now dealing with in all areas of medicine. We are no longer competing in an Irish market or a UK market, rather we are competing with Australia, New Zealand, Canada and the United States of America. What else do we need to do besides providing a new contract? What else do we need to do to keep medical personnel in Ireland and to provide a better level of service at community level?

Michael Harty (Clare, Independent)
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I thank the Senator and I apologise for misnaming Senator Burke earlier.

Margaret Murphy O'Mahony (Cork South West, Fianna Fail)
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I welcome the witnesses and thank them for giving up their valuable time to speak with us today. Dr. Murphy and Dr. O'Brien have said that prescribing antidepressants reflects a lack of psychological therapies and a lack of social therapies. This is serious and has the potential of snowballing and becoming more serious. Do the doctors have statistics to back up this contention and could they comment further on this issue?

The committee recently discussed the need for GPs to be transparent on the issue of gifts received, for example, from pharmaceutical companies. Do the witnesses feel that this is relevant with regard to the overall regulations around prescribed drugs? Perhaps the doctors will also comment on the medicines management programme.

Professor Horgan said that trainees are taught to combat the rise of antibiotic resistant bacterial infections. This is an ongoing concern. Surely training is not enough. Will Professor Horgan please comment on this issue?

Will Professor Fahey explain why he believes that electronic prescribing and dispensing of drugs do not interact effectively? Are there any plans to introduce the system that is currently in place in the UK?

Louise O'Reilly (Dublin Fingal, Sinn Fein)
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I thank the witnesses for their attendance at the committee this morning and for the information they provided.

Reference was made about access to supports and therapies and that perhaps there is an increase in drugs being prescribed due to the lack of the therapies. Would this be true of drugs for pain management? In the absence of access to proper physiotherapy, are GPs finding themselves in situations where they now have to prescribe painkillers? Would we see a reduction in the amount of pain management medication being prescribed if the resources and personnel were available in the primary care centres and if there was a fully functioning primary care team that included physiotherapy and other therapies? We are aware that these services are not in primary care centres but would this be more appropriate? Could it be better managed if more supports were available in the community? Perhaps the witnesses could give their views on where those supports should be based and how people might be able to access them. I understand that the majority of supports that are provided are in the private sector and are for people who have the money, and that the supports are not available for people on medical cards.

We cannot sit here and not talk about the pain medication patch, Versatis. This issue has been in the media where it was highlighted that the level of use of the patch in Ireland is out of kilter with its use in other jurisdictions. Perhaps the witnesses could comment on this issue in the context of the availability of therapies.

I have another query that is related to the use of Versatis. Is it the witnesses' opinion that GPs want to be in a position to prescribe it but cannot do so? Clearly GPs were prescribing Versatis, and I am sure the witnesses will tell me the GPs were prescribing it in line with procedures and so on, and that is fine. They were, however, prescribing it and now they cannot. Are there other drugs such as this? Are GPs sitting in their surgeries this morning with medical card patients in front of them thinking, "I would like to be in a position to prescribe these drugs"?

Can the witnesses give an estimation of whether that is a problem? We are currently debating legislation on the eighth amendment. People know my view on that which I will not rehearse as it is not for this committee. In the event that the amendment is repealed, it is proposed to roll out a GP-led model. I do not propose to go into the merits of that, but will specific training be required of GPs and how long will it take? Are we equipped to upskill GPs in the event that the eighth amendment is repealed?

Dr. Murphy said that having controlled the issue for polypharmacy, the odds of potentially inappropriate prescribing in 2012 compared to 1997 have reduced by 60%. What he is saying is that, in essence, we are prescribing more drugs but getting better at prescribing them. How do we fit with the rest of Europe on this? What I have read in the newspapers indicates that we are out of line and have a problem as a nation with prescription drugs. I am sure Dr. Murphy has seen that. Clearly, we are not writing the prescriptions for ourselves; they come from somewhere. Perhaps Dr. Murphy could give us a view on that.

As to nurses prescribing, is there much interaction between the GP service and nurse prescribers? Are there many nurse prescribers in the community? Could we make better use of the skills of nurses within the community with regard to prescribing?

Michael Harty (Clare, Independent)
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We might start with Professor Fahey. If there are other questions, we can pass them down the line.

Professor Tom Fahey:

Senator Colm Burke asked about comparisons with other countries in relation to polypharmacy and demographic trends into the future. We are not that far out of kilter with other countries. Every country in the developing world has experienced a substantial increase in the use of medicines which, by and large, has been a very good thing. We should not forget that. While we can, rightly, worry about inappropriate medicines, many of these drugs are very efficacious and helpful for patients and they have improved the length and quality of people's lives. While that is likely to continue, I do not know if many projections on demographic trends have been done in that regard. Most of the focus now is on trying to alleviate errors of omission. In other words, we must prescribe drugs which we know are effective to patients who benefit from them. Then there are errors of commission, which are those Dr. Mark Murphy just mentioned where potentially inappropriate drugs are prescribed and the risk-benefit ratio is marginal at best and potentially harmful. That is the context of what has happened. As we have all seen over our professional careers, the main challenge is to get the balance right in terms of drugs which are effective and helpful for patients while reducing as much as we can the use of potentially inappropriate drugs.

Professor Mary Horgan:

I was asked by Deputy Murphy O'Mahony about antibiotic resistance and whether training was enough. More than training is required. There needs to be ongoing education, not only of health-care professionals but of the public too. Not all infectious diseases I see require antibiotics. Many of them are viral infections for which there may not be any treatment. It is often fluids and paracetamol that cure those. People are under pressure to get back to work and get their kids to school and it is important to keep that in mind, but ongoing sustained education of the public is important. Immunisation is important also, in particular for influenza. We had another outbreak this year. There is a very effective vaccine available. While it changes a little from year to year, it is safe and effective and it prevents infections. There are other vaccines, for example the pneumococcal vaccine which prevents a certain type of pneumonia. With that, one can reduce the use of antibiotics. A lot of us may also prescribe courses of antibiotics which are a bit too long. Using shorter courses of antibiotics can cure a lot of the infections we see.

Lastly, it is important to educate doctors on prescribing the correct antibiotic for the appropriate infection. Sometimes doctors prescribe very broad spectrum antibiotics for an infection such as cellulitis which can be targeted with a very narrow range antibiotic. This is just a reminder on prescribing. Just because an antibiotic is new and more expensive does not mean that it is the best one for a particular condition. There is a need for ongoing education and training on prescribing that should be integrated in our daily practice.

Margaret Murphy O'Mahony (Cork South West, Fianna Fail)
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Public awareness.

Professor Mary Horgan:

Absolutely. Public awareness is really important. Sometimes there is no quick fix for infections, particularly viral infections that we are all exposed to.

Louise O'Reilly (Dublin Fingal, Sinn Fein)
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Would the introduction of near-patient testing help with that? I have no expertise in this area, but I have spoken to people who say individuals do not like to leave the surgery without a prescription. Their thinking is that as they have paid their money, they want to get something for it. In the event that general practice had access to near-patient testing, would that enable the doctor to be able to target infections with specific rather than broad spectrum drugs?.

Professor Mary Horgan:

Yes, absolutely. People with many of the common infections present at general practice surgeries. If the doctor had point of care testing for Group A streptococcal infection or influenza, the doctor could target what they need to treat, or it would indicate if the patient needed treatment at all. That would be an important resource on the front line, of which my colleagues in general practice would avail.

Professor Tom Fahey:

To add to that, there are strategies that can help patients and reduce the need to take antibiotics, such as negotiating with patients. One can give a patient what is known as a delayed prescription. One can give somebody a prescription, but inform him or her how long the illness will last, leave the decision to take medication with the patient and give him or her appropriate safety netting advice on what to do. All the evidence shows that only 15% of people use the prescriptions but it also de-medalicalises them so that the next time their child or they themselves get an infectious-like disease, they manage it appropriately without seeking antibiotics or help from their GPs.

Michael Harty (Clare, Independent)
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I call Dr. O'Brien.

Dr. John O'Brien:

A number of questions were raised and I suppose there is a common piece that perhaps ties many of them together. Some 40% of the funding of general practice has been taken out of the system. The first point that one must realise is that this has had consequences. GPs need time with people for a variety of reasons. The management of medication is only one of those reason, but there is also the management of their other problems, such as social and psychological problems. In order to provide time, one needs staff and staff cost money. This is linked to the issue that we are losing 20% of our GPs each year. They are choosing to go abroad. Their career opportunities are being impaired by what is taking place.

On the question of Versatis, it is worth noting that today there will be approximately 650 people on trolleys and some 500,000 people are waiting for appointments. Where do those people go for care? They actually end up in general practices and there is little in the line of immediate support in general practice for many of the conditions people have. We are talking about psychological therapies, physiotherapy and access to consultations with consultants, but those services are not available. The GPs are left in a predicament where they have to do something with the person who is in front of them who may be in pain. Not all of the 500,000 people who are on waiting lists are in pain, but some are. It ends up that medication is tried and if it is effective, that is great. Everybody has a pain tree, so one might start in the first instance by taking paracetamol and then one might take opioids.

Another is that one does not like to use non-steroidal anti-inflammatories in elderly people because of the impact on the kidneys. One might then wonder if there might be a neurogenic aspect to it or whether a Versatis patch might be a suitable way of prescribing in respect of a particular person. The Versatis patch is now much more difficult to get, so one finds oneself scratching around for other forms of nerve-blocking agents. As a result, one looks at anti-depressants, which are used but which tend to sedate. There is increased use of pregabalin, which has the brand name Lyrica and of which the members may have heard. It diverts prescribing into other areas. As a result, that issue arises again. The net problem is that there is not enough provision where it is necessary. It is necessary to bring the guns up to the front line. The front line is general practice. GPs deal with their patients in a holistic way and on a continuous basis. There is a whole iterative process that takes place and they are comprehensive, dealing with everything from people with diabetes to children with ear infections. If one is prepared to bring the assets to bear in the place of least expense and at the point of earliest contact, one is likely to have the best impact possible. If one does not do so, one is in trouble. We see the trolley numbers, the waiting times and the numbers on waiting lists, but what we cannot see is the contraction in the amount of time that GPs have to give to their patients, which is a major source of much of what the members are speaking about this morning.

Dr. Mark Murphy:

I will take a number of the remaining questions, some of which are difficult. Senator Colm Burke asked about ehealth. It is a very heterogenous, complex and large phenomenon. We are very saddened to see the loss of Richard Corbridge. We need to retain people and build incrementally. It is a loss to our health system that multi-annual capital funding was not put in place in respect of this. Professor Horgan and I would agree that it is not about blaming GPs and community-based doctors or hospital doctors, but errors can happen with handwriting and paper. That is the reality. My practice lives off fax machines, which is not good enough. Professor Fahey has shown examples of prescriptions that are illegible. I am frequently unable to read a prescription of 16 drugs, and would not be able to contact the prescribing doctor in the hospital. I am not blaming that doctor. That is a State error, because we have not invested sufficiently in electronic discharges. Electronic referrals have started, which go to the hospitals, and I now do that. It is very useful for the clerking doctor in the emergency department, but we need a full roll-out of electronic discharges when the patients returns to me. We are ready to go on electronic prescribing but, unfortunately, our electronic health records, which have been there for 15 years, do not talk to the secondary care electronic health records, nor do they talk to the pharmacy electronic health records. We are ready to go now. The question of timescale is one for the Department of Health and the Minister to answer. It also requires funding.

GP training numbers have increased to 202 this year. We have now filled 194 places, which is welcome. On whether we can reverse the exodus with a new GP contract, I am of the view that if GPs can do what they are trained to do and manage chronic illnesses, access diagnostics and have a satisfying work environment, we will absolutely retain them. I am very committed to that.

Responding to Deputy Murphy O'Mahony, to put it in context, GPs manage the majority of mental health problems in the State. This includes patients with severe anxiety, generalised anxiety disorder, panic attacks, severe depression and labels that we do not even use for people - just mental health complex phenomena. In my practice, I probably start patients on anti-depressants each week. They work and there is a strong evidence base to show that they are effective. They are in every guideline for managing mental health problems across the world for moderate and severe depression. The first-line treatments are lifestyle, social treatments and psychological treatments. I am afraid that sometimes those psychological services are not there. In the case of private patients, I had a patient recently who spent €1,200 accessing cognitive behaviour therapy for their son aged 15 years. It is an absolute disgrace.

That patient did not start on anti-depressants, although that would have been a lot cheaper. First-line therapy was started but it is prohibitively expensive. I am afraid that it can take a GMS patient up to six months to access psychological services which, when accessed, are excellent. That is the reality.

Gifts from pharmaceutical companies is a complicated issue. I personally do not see pharmaceutical company representatives but indirectly, a lot of our medical education is partly funded by the pharmaceutical industry. It is not a black and white issue but I personally do not deal with company representatives. Transparency is absolutely required in this area. A recent development in this area is the IPHA's Transfers of Value register, which allows one to go online and see who has voluntarily declared income from pharmaceutical companies. The voluntary aspect of that probably needs to change. We need to know those numbers and I would stand over that.

The medicines management programme is an excellent programme run by the HSE that delivers education to patients and doctors. Doctors always need to improve quality and standards. In terms of antibiotic stewardship, for example, it has developed a suite and platform to enable GPs and patients to understand appropriate prescribing. However, sometimes that involves a transfer of workload and that must be factored in, as a matter of basic respect.

I will deal briefly with Versatis before touching on nurse prescribing and the eighth amendment. We can only prescribe cost effective drugs. If there is an indication, we will prescribe it and for neuropathic pain, the prescribing of Versatis by GPs is both legitimate and understandable. I am not blaming anyone but much of the Versatis prescribing came from the secondary care setting, that is, from pain clinics. As a GP, if I referred a patient to a pain specialist and he or she waited for 18 months to be seen and was then referred back to me, I could not just say that I did not agree with the pain specialist, if the drug had been prescribed already. I welcome the initiative to reduce inappropriate prescribing but as a GP, I am expected to spend 15 minutes on an online platform for each patient. As a matter of respect, the HSE must talk to our representative bodies about that. Let us do it and let us consider other drugs on which money can be saved but we must bear in mind that there is a cost aspect to that.

On nurse prescribing, I work with a nurse who is a prescriber and I believe we should get going on this. This is all part of the GP contract. There has been a feeling within general practice for the past 15 years that they have not believed in the current model of general practice. They are finally coming around to that. It is to the detriment of patient care that funding to allow practice nurses to train in this area and to upskill has not been provided. That must happen. Obviously there are quality and educational issues that need to be factored in but most other health care systems have allowed nurses to expand their portfolio of skills and we should allow that to happen here.

On the eighth amendment, Deputy O'Reilly knows my personal opinion. However, I am speaking here on behalf of the Irish College of General Practitioners. The college made a submission to the Citizen's Assembly and to the Oireachtas Joint Committee on the Eighth Amendment of the Constitution, both of which came up with what they believe are workable recommendations. There is a problem with the phrase "GP led" because in the future, we do not know what model will develop. Specialists and clinicians who have an interest in this area, whether in secondary care or in the community, will provide the service. I know there are many clinicians who will do so and that model needs to be thrashed out and delivered. Early medical abortion is delivered with an abortion pill and 1,500 women here took that pill last year. We are talking here about mifepristone and misoprostol pills. There will be a licensing issue and that needs to be factored into the legislation. That is all I can say on the matter. We are talking about two tablets that will need to be licensed.

Michael Harty (Clare, Independent)
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We will now bring in our next contributors, Deputies Durkan and O'Connell.

Bernard Durkan (Kildare North, Fine Gael)
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I thank our guests for their attendance this morning. I wish to raise the issue of e-prescribing and the cost-benefit analysis of same. What are the potential benefits of a greater reliance on and upgrading of technology in terms of making prescribing more effective and efficient?

For instance, how do we rate at the present time in comparison with other jurisdictions in terms of our GPs, consultants, hospitals and so on? I got a report from somebody recently to the effect that we are light years behind. Everything has a waiting time. One has to wait for X-rays, for scans and for reports. This waiting time intrigues me. I have raised it in this committee on numerous occasions in the past. I presume that technology is the way around that issue. However, if the person to whom a message is given at a particular time also has a list of people waiting, it does not serve any useful purpose at all. Everybody is in a circle of waiting. Essentially I am asking how fully that issue has been studied. How do the witnesses see efficiencies in that area benefitting the patient?

On under-prescribing and over-prescribing, how much evidence exists of under-prescribing, for example, ultimately resulting in a longer duration of prescription by virtue of an inadequate prescription in the beginning? This is something that certainly has been brought to my attention in the past. As a result of trying to ensure that we do not cause the problems about which we are all worried in respect of resistance to antibiotics, there is a tendency to under-prescribe, resulting in a longer period of medication, which ultimately has the reverse effect. The patient consumes far more than they would have done if he or she had got an adequate prescription in the beginning.

The last question I want to raise relates to Versatis and the alleged excessive use of it. I take the points that have been made in respect of solving the particular problem which presents itself at a particular time. I am concerned, however, that in comparison with the UK, we seem to be way ahead in terms of prescription in that area. There has to be some reason for that. It escapes me at the moment. I do not know what it is. If it is an instant solution, why is it not an instant solution in the UK? I fully appreciate the fact that pain can be a factor that can drive people to seek the ultimate solution in the shortest possible time, but why is it that our use per capitais way ahead of that of the UK? To what is that attributable?

Michael Harty (Clare, Independent)
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I thank Deputy Durkan.

Bernard Durkan (Kildare North, Fine Gael)
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The Chairman looks shocked. Did he think I was going to go on?

Kate O'Connell (Dublin Bay South, Fine Gael)
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It must be a miraculous contribution that will go down in history. I do not think Deputy Durkan had his Ready Brek.

Michael Harty (Clare, Independent)
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Deputy O'Connell can take up his extra time.

Kate O'Connell (Dublin Bay South, Fine Gael)
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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.

Michael Harty (Clare, Independent)
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Does the Deputy have actual questions for the witnesses?

Kate O'Connell (Dublin Bay South, Fine Gael)
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Yes, I do. Do the witnesses have any views on the use of combo drugs like Vimovo that are coming onto the market? Two molecules are combined by a company to reduce the drug from two to one. However, the two components are far cheaper individually. We have seen an emergence of that kind of smartness, as I would consider it, on the part of drug companies, where two off-patent drugs are combined. For the prescriber, it is sold to some extent as having the patient on one tablet instead of two, leading to better adherence to a regime. How can we deal with that and the cost of it?

Somebody spoke about cognitive behavioural therapy and antidepressants. This is a huge issue and I have seen it in community regarding people with certain means, the mental capacity, and the people within their lives to assist them. I know one particular girl in her 30s who spent €5,000 on cognitive behavioural therapy over six months. She did not want to go on antidepressants. She did not really have the means but she got them and she was fixed up fine. That is just prohibitively expensive for anybody, however. In the case of a 15 year old, it is so important that, where possible, we do not medicate young minds unless absolutely necessary. If there is a cognitive behavioural method available, it should definitely be prioritised for young people.

It was said that there were 650 people on trolleys. There are now 362 people, which is down 20% on the same day last year. I have to do something for the Government while I am here.

Professor Tom Fahey:

Going back to prescription pattern monitoring and the audit and usage of effectiveness trends for prescribed medicines, I will try to summarise some of the issues. Prescribing is such an important and, I can see from the questions, impassioned issue for everybody in Ireland. I want to put things in the context of initiatives that are going on at present and how we might build on them. There are some very good and important initiatives in respect of prescribing under way Ireland at the moment. I will mention two. On prescribing guidelines, there are two clinical care programmes that I think do pretty good work.

There is no particular conflict of interest in my saying so. The medicines management programme does good work because it provides guidance on prescribing practice that is based on current evidence. Deputy Durkan asked what will happen in terms of Brexit. We have evidence-based prescribing guidance already but we need to build on that through the medicines management programme.

Professor Horgan is better able to talk about antibiotic resistance than I am. We have a good clinical care programme in the primary and secondary care sector that provides very good evidence on first and second line antibiotic prescribing. To build on such initiatives, and returning to the reason for my attendance here this morning, there is an e-prescribing issue. We are falling behind other countries, and European countries in particular, in the aggregation and usage of prescribing data and in how we might continue to improve both the equality and safety of prescribing. That is what we need to take away from today. We have a base of good initiatives but we need to develop a national system where access to public data on prescriptions, retained as part of the Primary Care Reimbursement Service, PCRS, must be more widely available. I mean anonymised data that researchers or postgraduate training bodies or quality improvement bodies can access and use in realtime for prescribing, reflection, practice, audit and feedback. We should prioritise the initiative.

Lastly, there was a question about the high-tech drug versus a generic substitution. We are going in the right direction in terms of generic substitution. The preferred drugs initiative, via the medicines management programme, reflects this. Again, we can do more about that by reducing or enhancing the amount of drugs that we prescribe generically.

Michael Harty (Clare, Independent)
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I wish to comment on generic substitution. Quite often a patient may get 12 different generic substitutions in a year. In other words, he or she goes into a pharmacist and receives a product. On his or her next visit the chemist will suggest that another generic substitute is the same as the last one but it has been produced by a different company. People react to products in different ways. Not all generic drugs are the same and not all generics drugs are the same as the proprietary drug. Patients using multiple versions of the same drug is a huge problem and it is very difficult to identify the culprit when they, inevitably, develop an adverse reaction. Multiple generic substitutions is an issue for patients and GPs.

Professor Tom Fahey:

I agree. There is a peculiar set-up in Ireland as many generic manufacturers provide different generic drugs. Earlier I mentioned pharmacists. I work in the research area and receive a lot of helpful advice from pharmacy colleagues. General practice and pharmacy practice can work more closely together but, again, that goes back to the prescribing aspect. Let us say one has a list of generic drugs, and please correct me if I am wrong about the following, a pharmacist can prescribe an equivalent generic if he or she has it in stock. One must convey such information clearly to the patient. We must move in that direction because otherwise we will have a very high proprietary prescription rate and a much more costly prescribing environment here.

Michael Harty (Clare, Independent)
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I thank Professor Fahey for his comments and call Professor Horgan.

Professor Mary Horgan:

I shall pick up on the point made about pharmacists operating in a health care setting. In the States I was trained in the area of infectious diseases where the hospital pharmacist was absolutely essential. Not only did the hospital pharmacist save about $1.5 million a year in the infectious disease service of a large university hospital, they contributed to good outcomes for patients. Pharmacy and medical students are taught safe prescribing at undergraduate level but we should do more with hospital-based pharmacists at postgraduate level. Such instruction is given for antibiotic stewardship and cancer chemotherapy.

However, it must be expanded above that. It should be a team-based approach. That is how we should be educating our trainees. We recruit very smart people into undergraduate programmes in pharmacy and medicine. The two groups can work very well together and that should continue. I can speak for a hospital where most of our trainees, members and fellows are based. Dr. Mark Murphy and Dr. John O'Brien might wish to comment on that. More integrated education at postgraduate level is essential. I frequently ring the pharmacist to ask about adverse drug effects and interactions before I send patients out.

The other thing I find helpful is that I always look at the drugs the patients are on when they come into hospital because I do general medicine. A lot of the time they do not need to be on all of the drugs. This is about working with the pharmacist to go through everything, what the patient needs, what interacts with what and what we can stop.

Dr. Mark Murphy:

I will also start with the role of the pharmacist. There is a specific paragraph here and I apologise to Deputy O'Connell if I did not quote it. However, it is here and I have said it at previous meetings. The first sentence is that the community pharmacist is an essential and extremely valued member of the primary care team. I talk with multiple pharmacists each day. They are critical to the delivery of safe and effective care. As we move forward we need to have a debate about the fragmentation of care. We have a privatisation and corporatisation agenda in the Irish health care services which has absolutely undermined the ability of our health care system to function effectively. Our system should have moved to GP-led, community-based care working closely with community pharmacists, but it has not. We have been moving increasingly away from that. We need to disentangle that fragmentation.

There are enhanced roles of practice-based pharmacists, practice-based nurses, nurse prescribers and enhanced roles for community pharmacists as well. However, when talking about prevention of cardiovascular disease or addiction services I do not want the services to be further fragmented for patients. They need to have a system where they are not over-medicalised and made more vulnerable by having multiple sources and avenues of accessing health care. Consider contraception. We have to balance that with access. The Deputy has been a particularly strong advocate on sexual and reproductive health care. We have to ensure that all patients have accessible care. I believe that is primarily in the GP setting but not only there, and the Deputy has highlighted a few reasons. However, we cannot fragment care further.

I will make a couple of comments on the issue of advertising. General practitioners are extremely frustrated with the manipulation and erroneous marketing and advertising on radio and in newspapers by private hospitals and, indirectly, pharmaceutical companies. They are targeting vulnerable patients and it is an absolute disgrace. It promotes an over-medicalisation in our society. We must think long and hard at State level about the harm that is happening because of this agenda. For GPs it is very upsetting to see the anxiety and frustrations visible in our waiting rooms because of the frightening perception that is created in patients' minds.

Combination drugs is a complicated issue. One is balancing compliance, because it is one medication rather than two, versus cost. We have to be responsible in the health care system. We must prescribe cost effectively. When we spend somewhere we lose out somewhere else. With regard to high-tech drugs, we spend €700 million on high-tech drugs while we spend approximately €1.4 billion on other pharmaceutical products. It is astronomical. It is very upsetting, for example, for a provider of home care packages in the community, one of the most valuable interventions one can make to keep people living at home for longer. We cannot afford home care packages but we can afford medications at astronomical costs with very limited benefit.

Some drugs have a definite cost-effective balance but others do not. We can work that out in the medicine management programme, which Professor Michael Barry has specified. The politicisation of certain drugs has led directly to the reduction of community-based care. We need to get very honest about that in our society. We have a responsibility, given that we have one budget in health care, to spend money where we get a bang for our buck. I will let my colleague, Dr. John O'Brien, talk about formularies and guidelines.

Dr. John O'Brien:

We do not want to be the dog in the manger. That is not the issue. There are issues around fragmentation which need to be taken on board. The reason a GP needs to lead primary care is not because he or she is such a wonderful thing, but, rather, because the model of general practice is one which provides for integrated care, which is what is proposed in Sláintecare. Integrated care depends on the GP delivering care in a holistic manner, which means that one is looking at all of the contexts of a patient's problems, be they biological, social, psychological or even existential. The model has to be comprehensive and deal with everything. A GP may deal with lupus, diabetes, oesophagitis or psychiatry. The care has to be totally comprehensive.

Another important aspect is continuous care. This is all within the European definition of general practice but I am distilling it down for the committee. Continuity of care is important because with each consultation another twist in the relationship with the doctor and patient takes place. All of that iterative building over a period leads to a resource which the patient can draw down during times when they are in difficulties. It also helps in terms of balance.

We discussed multimorbidity, which means that a person has a range of different diseases. If one is going to introduce into the community specialist nurses in cardiac care, respiratory care, diabetes or whatever else they will all follow the guidelines pertinent to their area of expertise. Who takes all of that, marries it together and integrates it for a single person? That is what a GP should be doing.

This brings me back to the issue of time. If GPs are not given enough time to do that, then they cannot do it. People will go on to waiting lists or into casualty departments where they should not be, which is another cost to the system. Savings can be made by taking a lot of funds out of general practice, but we lose out on a whole load of other things, including the budget, which is what we are discussing today.

Michael Harty (Clare, Independent)
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We are here today because there is an expectation that there is a pill for every ill. Patients have an expectation that is a cure for everything. It is very difficult to get that message across. Professor Fahey has a prescription with 14 items on it for a patient who has vitamin and iron deficiencies, probably has atrial fibrillation, has a pancreas deficiency, has chronic obstructive airways disease and is taking MST opiates for pain, something to counteract constipation and a PPI to protect the tummy against all of the other drugs he or she is taking. It is a very interesting prescription and learning tool.

When I have students with me, I often show them a prescription and ask them which two items they would remove from the list because they are unnecessary. As professionals, we can be drawn into the idea that there is a pill for every ill and, as a consequence, there can be a prescription with 14 items. If an elderly patient has a prescription with 14 items the likelihood of compliance is low unless the medication is blister-packed, and there are issues around that. Perhaps the witnesses might comment on the perception that there is a pill for every ill.

Reference was made in one of the opening statements to low value items having a high cost and how these are screened out in the context of medication reviews. In regard to general practice, general practitioners and geriatricians are probably the only generalists practising medicine now. As stated, to get a holistic picture of a patient general practitioners often have to distil down through prescriptions. I note Professor Fahey is smiling. I am sure he will have some comments to make on that issue.

In regard to Sláintecare, the report is with the Department of Health. We have not yet had a reaction to it. It is a radical report in that it proposes so many different changes to our health system, one of which is a transfer from hospital to general practice and community services, which are essential. It is important that we have a robust primary care service because the rest of the health service is built on sand. Perhaps the witnesses would like to extrapolate on that issue on the GP contract, which is a 24-7 and 365 day contract and on the concept of the doctor taking on all of the responsibility and paying for everything which is dead in the water.

Professor Tom Fahey:

On Deputy Harty's first comment, generally speaking, I hold my clinics, see my patients, do some house calls and I then update my repeat prescriptions. Usually, I see between ten and 15 people per morning clinic such that the clinic mentioned was a fairly typical one. On prescription pattern monitoring and audit of usage, this script is not that bad; it is possible to read it. What the Deputy is doing is trying to surmise the indication for these drugs but the indication is not on this prescription. Under the current system, the prescription of a drug is not linked to a diagnostic code for indication. This is something we should have because it enables people, either in the community or the hospital sector, to make more rational decisions about the need for a prescription and to have a meaningful discussion with the patient. If we had an interoperable system that spoke to the hospital system, we could then make a joint decision or at least identify that a person has been in a hospital and was refused a drug for a particular reason.

The system around prescribing needs to be enhanced in the short term. Education and training in Ireland is reasonably okay, but it can always be improved. The systems around supporting prescriptions in the community, dispensing pharmacies and hospitals is lagging behind and this should be addressed.

Professor Mary Horgan:

The first thing I do when I see a patient on a ward round is to review their drug list to determine what he or she is on and the reasons for it. We try to incorporate this practice into our training. In 1995, when I was training in the US, I led the roll-out of a pilot on electronic medical records in a large institution. I work in a system here within a hospital where there are no electronic medical records other than discharge summaries and these are not available to everybody. Some 23 years on, I do not think we are hugely further along. If we cannot do everything together, why can we not do it piecemeal? Perhaps the patient journey from prevention to general practice to hospital care and back to general practice is the priority that e-health needs to be working on.

Dr. John O'Brien:

I refer to the Chairman's comments about the pill for every ill. One of the things that worries me is hearing people talk about the worried well. Since when were the well worried? I think people do have an expectation of medicine and what it can do for them which is perhaps not exactly what medicine can do. As part of their relationship and dialogue with their GPs some of this can be thrashed out, although I am back again to the issue of time. We spoke earlier about issues that arise out of advertising, specifically the advertising of medication but there are even campaigns such as those I have heard on the radio asking listeners whether they could have cancer or heart disease or suggesting colonoscopies. This can be driven by marketing and advertising, but equally I think there is a national admiration for what medicine can do, and rightly so. However, perhaps that admiration goes a little too far in terms of what it actually delivers because what it does not say is that medicine can do this but there is a cost. It is a question of that balance between the benefits that people will accrue from various interventions and the cost to them of all that. Going back again to the business, we were talking about the advertising of medications on the television and radio - on the radio anyway. I was away recently and listened to CNN for two hours, and in that two hours there were separate advertisements for 12 different medications and one for colonoscopies. I do not know that that is a wonderful place for us to be going; I think we need to back away.

Lastly, when people get to the back end of their lives, very often they are on a great deal of medication and have had a great deal of intervention. Whether further intervention, or even the medications they are already taking, is appropriate for their care and what their care will be at the end of their lives are questions that need to be planned with them. They need to have those kinds of discussions with their GPs and that is not happening because of lack of time. The net effect is that people who really should not be in emergency departments are ending up there. This is inappropriate care and goes back to a wider exposition of the Chairman's comments on a pill for every ill.

Louise O'Reilly (Dublin Fingal, Sinn Fein)
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I have just one question. Social Justice Ireland published a report recently. There were a number of elements to it, but Social Justice Ireland identified a particular category, a regrettably growing number of people whom one could loosely call the working poor. These are people who would not necessarily qualify for medical cards but who have no immunity from illness either so will have occasion to visit their GPs. I appreciate the witnesses may have to follow up with us on this, and that would be fine, but could they offer us a view as to whether, in their experience, there are people for whom GPs may prescribe medication but who do not have the means to fill that prescription and who may find themselves at the doors of accident and emergency departments or elsewhere because they are not getting the treatment they need, even though they may have been prescribed it? This is something I have seen but it is anecdotal. Is there evidence of or information on this that we might be able to look up?

Kate O'Connell (Dublin Bay South, Fine Gael)
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Following on from Deputy O'Reilly's comments, we heard at the Joint Oireachtas Committee on the Eighth Amendment of the Constitution from the Irish Family Planning Association that 17% of women outside the medical card cohort found the price of contraceptives, including consultation fees and prescriptions, to be an issue. Further to this, we learned at some stage on that committee of the huge expense of long-acting reversible contraception - for example, Mirena. People put it off because of the price. It is allowed under the drug payment scheme, but there is the insertion and so on. It is therefore worth noting, following on from Deputy O'Reilly's comments, that one in five women without a medical card has difficulty accessing contraception due to cost.

Keith Swanick (Fianna Fail)
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I apologise for coming and going; I had a few media interviews and a Commencement debate. I have been speaking about loneliness and have set up a task force to address the issue. We all know the devastating effects the epidemic of loneliness can have on both physical and mental health. It is estimated that 400,000 people in Ireland suffer from loneliness, and more than 9 million people in the UK, where it costs the NHS €35 billion. That is an incredible amount of money. It is linked with an increase in mortality rates and dementia, and is considered to be as bad for a person as obesity or smoking 15 cigarettes a day.

There is a taboo around loneliness and a shame around admitting that one is lonely. People will often say to me that they are depressed but when asked, they agree that they are lonely. They are not really depressed but rather are lonely. Do the witnesses think that the medical profession has overcompensated in terms of prescribing unnecessarily for those people? Could savings be made in that respect?

Dr. Mark Murphy:

I will touch upon the question asked by the Chair as to how we know that a drug is cost effective. In an evidence-based consultation, a doctor uses his or her own clinical experience. He or she also considers the evidence available about the drug, which will often have limited benefit but which is beneficial nonetheless. There may be side effects of the drug. The decision is shared with the patient and their preferences are considered. That takes time. For a patient who is on 14 different drugs, considering the fact that all of those drugs are dynamic and that at any one time they are not definite or absolute forever, a medication review every six months takes a significant amount of time. If one wants to take the prescription of medication seriously, apart from the capital infrastructure to make prescribing between interfaces safe, that time needs to be resourced. This is particularly true in the last five to ten years of a person's life. If a person is over 80 or 90 years of age the evidence base for those medications is limited, particularly for primary preventative purposes, and we need to fund that time to have those long conversations with patients. I believe we would reap dividends in terms of a reduction in health care spending.

On Sláintecare, the Irish College of General Practitioners really wants to commend the Chair and every Deputy and Senator here on their hard work in advocating for a long-term vision for a fairer and better health care system that is more community orientated. We absolutely support the initiative taken. We really are getting frustrated that the Department of the Taoiseach and other high offices have not taken this on to implement it.

On Social Justice Ireland and the working poor, it is those persons who are above the means threshold for a medical card, who have to pay to see the GP and who perhaps must pay €149 every month for their medications. It is extremely unfair, and it is a definite phenomenon that those patients are not compliant in returning to us or with taking their medications because of cost. Some of those patients end up with catastrophic out-of-pocket payments, which is simply wrong and immoral. It is a difficult issue, and I believe that Sláintecare is seeking to address it.

On the question of loneliness, I agree entirely with Senator Swanick. There are issues in the health care system about which we have to be honest. We cannot do anything about some of the issues. Much of the life expectancy improvement that has taken place over the last 50 years is not due to the medical profession but because of advances in other areas of the civic environment, such as education and social protection. A community health care system is very important and is useful for the prevention of loneliness. Having a day in a community hospital, accessing a GP, a public health nurse and a home care package are some of the benefits. However, we have to get real and not over-medicalise this. This is an issue of a fragmentation of our communities and a change in culture. It is a wider civic societal issue as well. GPs have a pivotal role in identifying loneliness but in terms of social prescribing and other phenomena to try to help loneliness, it is a major issue and I believe we should not over-medicalise it. It is a very important issue to raise.

Keith Swanick (Fianna Fail)
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I acknowledge that the witness is very busy, but he might take the time to make a submission to the Loneliness Taskforce at www.lonelinesstaskforce.com. We would be very grateful because we intend to publish a report in May.

Dr. John O'Brien:

I reiterate a lot of what has been said. This brings me back to the business of holistic care. In the main, depression does not fall out of the sky. Generally speaking, people are depressed for reasons which are immediately clear. This is not be true in all cases, but it is true in many. Certainly, the social circumstances of the individual will have an impact on his or her psychological state. As to how that all plays out, two particular pressure areas in general practice are emerging. The first is deprived urban areas where the resources are just not there and the second is rural practice. Rural practices are shutting because they are not economically viable and large swathes of the countryside are without GPs. Patients use GPs in a manner which is not just about the ordinary taxonomy of diseases we were all taught in medical school. There is a lot more that transacts within a general practice than that. This part of what Senator Swanick refers to - loneliness. The loss of those critical services within communities is where all that stems from. The Chairman was involved in the "No Doctor, No Village" campaign. It is the critical end of things. The people who get the raw deal out of all of this every time with health are poor people. They have twice the problems of the rest of the community but they get the same level of allocation. That means they get half the service. I find that hard to stand over.

Michael Harty (Clare, Independent)
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During the Sláintecare report process, all members of the committee became expert in the inverse care law and Tudor Hart and could lecture on it by the time our deliberations had concluded. We had a very important meeting with Deep End Ireland, which outlined the inverse care law and the deprivation index that should be applied to payments and resources for general practice.

Coming back to the reason we are here, the media articles to which we responded were about the medical profession overprescribing anti-depressants, benzodiazepines, painkillers and opiates. There may or may not be a basis for that but certainly there is a delay in people receiving chronic care for conditions such as osteoarthritis and hip and knee replacements. I am very impressed with the prescription the professor has brought along because the patient is not on a sleeping pill or benzodiazepine. That is probably an exception to the rule because there is an increasing demand for benzodiazepines which we, as a profession, are trying to resist. Many years ago, GPs were accused of under-prescribing for depression. The accusation now, perhaps, is that we are overprescribing. Is there a response to that?

Dr. Mark Murphy:

I might start and then let my colleagues continue. Each of those drug classes is a separate issue which needs to be looked at separately. We have to stand over safe, high-quality prescribing. Are there cases when certain drugs should not have been prescribed? There is no doubt. There are human errors, complex phenomena and there may be certain doctors who might overprescribe a certain drug. That might be the case. It is true in every health care system. As training bodies and health care professionals, we all want to do our best and need a robust postgraduate education infrastructure which facilitates colleagues to have the very best evidence base and understanding of cost-effectiveness. We also need to provide them with time so that they can share those decisions with patients.

Some of the drug classes are more problematic than others. The case has been made for anti-depressants, which it is very appropriate to prescribe in very challenging psychological and social circumstances for patients without psychological services. Benzodiazepines are sedative medications. While raw prescribing shows that is going up, the extent to which people are prescribed a benzodiazepine for over eight weeks, which is known as chronic benzodiazepine prescribing, has decreased in the past 15 years. I have not started a patient on a benzodiazepine for more than eight weeks in five years. While I prescribe benzodiazepines once every few weeks, it is a short course and it relates to a variety of phenomena, for example, severe, acute bereavement. I give one tablet for back spasm where there is extreme pain. That is not wrong or inappropriate. Prescribing for more than eight weeks, however, is largely a legacy issue. Some patients are addicted and have been on the drug for more than 15 years. The ICGP works with colleagues in the RCPI and the HSE on guidelines to manage benzodiazepines and opiates. We will continue to work with these guidelines. It is a challenge to tell an 82 year old who has been on a benzodiazepine to try to come off it. It is a challenging issue. While we can probably do better, we have to be mindful of the personal and unique circumstances of patients. We will continue to promote the highest quality and standards going forward.

Michael Harty (Clare, Independent)
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I thank Professor Tom Fahey of the Royal College of Surgeons, Professor Mary Horgan of the Royal College of Physicians and Dr. Mark Murphy and Dr. John O'Brien from the Irish College of General Practitioners.