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.