Oireachtas Joint and Select Committees
Wednesday, 8 March 2023
Joint Oireachtas Committee on Health
The Role of Pharmacy Care in the Healthcare System: Irish Pharmacy Union
Seán Crowe (Dublin South West, Sinn Fein)
Link to this: Individually | In context | Oireachtas source
The format of today's meeting is usually ten minutes for questions and answers for each committee member. If there is time there may be a second round of questions. Apologies have been received from Senators Frances Black and Seán Kyne. Name plates in the committee room were unfortunately unavailable for use due to a technical error so I ask all members to be conscious of this when engaging with the witnesses.
Before we get to the main item on today's agenda, the minutes of the committee meetings of 28 February and 1 March 2023 have been circulated to members for consideration.
Are they agreed? Agreed. The purpose of the meeting today is for the joint committee to meet representatives of the Irish Pharmacy Union, IPU, to consider issues relating to the role of pharmacy care in the healthcare system. To commence the committee's consideration of this matter, I am pleased to welcome from the IPU Mr. Dermot Twomey, president, Ms Kathy Maher, chair of the pharmacy contractors committee, PCC, Ms Sharon Foley, secretary general, Dr. Susan O'Dwyer, head of governance and pharmacy services, and Mr. Jim Curran, director of public affairs and communications.
All those present in the committee room as asked to exercise personal responsibility to protect themselves and others from the risk of contracting Covid-19. Witnesses are reminded of the long-standing parliamentary practice that 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, or otherwise engage in speech that might be regarded as damaging to the good name of the person or entity. Therefore, if their statements are potentially defamatory in relation to an identifiable person or entity, they will be directed to discontinue their remarks and it is imperative that they comply with any such direction.
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, either by name or in such a way as to make him or her identifiable. I remind members of the constitutional requirement that they must be physically present within the confines of the Leinster House complex in order to participate in public meetings. I will not permit members to participate when they are not adhering to this constitutional requirement. Therefore, any member who attempts to participate from outside the precincts will be asked to leave the meeting. In this regard, I ask any members participating via Microsoft Teams, prior to their contribution to the meeting, to confirm that they are on the grounds of the Leinster House complex.
I invite Mr. Twomey to make the opening remarks on behalf of the Irish Pharmacy Union.
Mr. Dermot Twomey:
I am a pharmacist based in Cloyne, County Cork, and the president of the IPU. I am joined here today by Kathy Maher, a community pharmacist from Duleek, County Meath. Kathy is chair of our pharmacy contractors committee. Dr. Susan O’Dwyer is head of governance and pharmacy services. Sharon Foley is IPU secretary general. Our colleague, Jim Curran, director of public affairs and communications, is situated in the Gallery. I would like to start by thanking the committee for the opportunity to address it today. This discussion on the potential of, and challenges facing, community pharmacy is both timely and relevant.
The Irish Pharmacy Union is the professional representative and leadership body for community pharmacy. We have a proud tradition, developed over the last 50 years, of representing and advocating for the vast network of community pharmacists working in communities across Ireland. Our members are committed to delivering a high-quality, accessible and professional pharmacy service that puts patients first and optimises the health and well-being of society.
Community pharmacy is recognised as the most accessible element of our health service with an unequalled reach in terms of patient contact and access. There is a pharmacy in nearly every town and village in the country, with 85% of our population living within 5 km of one. Community pharmacy provides a ready-to-go health infrastructure which we believe can be utilised much better. The crucial importance of the sector and the willingness of community pharmacists to support patients was most apparent in the recent pandemic. Pharmacists ensured they remained open and accessible, providing an essential service at a time of great uncertainty. We played a pivotal public health role by delivering Covid vaccinations. To date over 1.3 million vaccinations have been delivered. Community pharmacy is a highly regulated profession with a commitment to patient safety and quality. Structures are in place to ensure that standards of professional competence and ethical conduct are clearly outlined, communicated to patients and independently inspected on a regular basis. Recent research shows that many Irish people view their pharmacist as the first port of call for their healthcare needs. Community pharmacists are voted consistently by the public as one of their most trusted professionals. We are indeed committed to the Sláintecare ethos of ensuring that the right care is delivered in the right place at the right time for all patients. We believe there is tremendous potential for community pharmacy to realise this ambition. We want to utilise our skill sets and facilitate pharmacists to work to their full scope of practice.
With that in mind we would like to outline some concrete proposals and concepts which could transform the delivery of care in the community. We believe these proposals will help to increase capacity in the healthcare system overall and support in the delivery of better healthcare outcomes. The first proposal I will speak about is the minor ailment scheme. The IPU is proposing a new scheme which holds significant potential to free up capacity in primary care, which we all know is under huge pressure. A minor ailment or triage service would be a community pharmacy-based service. It would be similar what is being implemented in Scotland as the Pharmacy First model. Under this scheme, public patients with minor self-limiting conditions would no longer have to make or wait for GP appointments. Instead, they would consult with their local community pharmacy, receive an assessment of their symptoms followed by a combination of advice, medication supply and-or referral to other services. Existing legislation for the supply and administration of certain prescription-only medicinal products prescription can be amended to provide a route for widening access to the range of treatments available. This would be available to both private and public patients, who would benefit from a wider range of conditions being eligible for assessment and direct treatment in their local pharmacy. The introduction of this scheme would demonstrate Government commitment to enhancing public health access, ensuring timely and equitable access to medicines, delivering quality patient care and, the key point, improving health outcomes. Such a scheme would support national healthcare principles of delivering care that is equitable, accessible, close to the patient and sustainable. Our studies indicate that this could potentially free up 1 million GP appointments, where patients could be treated in community pharmacies or referred as appropriate. This would be a clear example of an opportunity to radically reimagine the delivery of timely care within the community and deliver cost-effective, safe and desired health outcomes. The Irish Pharmacy Union proposes that work now begins on this as it will contribute to addressing immediate capacity issues within the health system.
On access to contraception, it is timely that I am before the committee on International Women's Day. The Women’s Health Action Plan 2022-2023 has demonstrated the commitment of the Minister for Health to prioritise the health of women in Ireland, which we wholeheartedly support. We were delighted with the introduction of free contraception and its further planned expansion and believe that reducing barriers to contraception can only enhance patient care. It has been reported on multiple occasions that women, both in Ireland and abroad, would prefer to obtain their contraceptive from their pharmacist. There is no clinical reason for oral contraceptives to be supplied only on foot of a prescription; with proper protocols this is a very safe and effective healthcare intervention. Experience in other countries demonstrates that reducing cost and increasing access is highly effective in terms of reaching populations who might not otherwise engage with health services, such as new communities, younger cohorts and ethnic minorities. Similar to the minor ailment scheme, we recommend that the Minister now moves to expand the range of medicines noted in Schedule 8 of the Medicinal Products (Prescription and Control of Supply) Regulations 2003, as amended, to include the full range of oral hormonal contraceptives and injectable long-acting contraceptives. Training and governance requirements can then be put in place.
On medicine shortages, medicines are the most common healthcare intervention within the health system. Medicine shortages and the management of patients' needs as a consequence are part of the core function and role of community pharmacy. The nature of our medicine supply chain and its globalisation means that this is becoming more complex than ever before. Pharmacists often have to source medicines from other countries to meet the needs of the local population. Given that pharmacists are experts with a unique skill set and unrivalled pharmacological knowledge, we advocate for the more effective utilisation of this skill set to manage medicine shortages at the point of patient access. This would facilitate therapeutic substitution of medicines without the need to revert to the GP for a prescription in cases where there is a critical shortage of medicines. Again, this is a relatively simple measure which will increase the speed of supply and reduce the stress on patients and pharmacy teams.
I will move on to discuss strategy and a chief pharmaceutical officer. As a country, we need to take a more proactive approach to the management of medicine shortages and indeed to pharmaceutical care in general.
One of the most fundamental and seismic changes that could be prioritised to unlock the potential of community pharmacy is to develop an agreed national strategy for pharmaceutical care. This would help to deliver better health outcomes for patients. This should be owned by the Minister for Health and driven by the appointment of a chief pharmaceutical officer within the Department. As with other professions such as medicine and nursing, this person should be appointed at a senior level in order that the strategy has power and currency.
It is our view that the proposals outlined would make a significant immediate impact by utilising the limited healthcare resources at our disposal better, and we are committed to driving them forward. However, we cannot do this without support. To deliver better health outcomes fully, the sector must be adequately reimbursed and invested in. June 2023 is the deadline for the Minister's commitment to review the fees paid to pharmacists. These fees have not changed since 2009 and have not kept in line with crippling inflation. Our average dispensing fee now is lower than it was in 2008. If community pharmacy is to do more to deliver essential health services, we need to be able to invest in our teams to provide them. Our GP colleagues have had the benefit of substantive talks, resulting in the 2019 GP agreement, which saw a substantial reinvestment in GP services. We are seeking equitable treatment. Community pharmacy now needs to see a similar reinvestment to support future service delivery.
This committee previously debated the crippling, slow progress regarding ICT and healthcare. A modern healthcare system needs functioning e-prescribing and ICT investment and a move away from legacy-based paper solutions. Without improvements in ICT systems to help streamline associated processes, there is now an almost unworkable administrative and cognitive burden associated with dispensing under the community drug schemes. We fully support the HSE's e-health vision to deliver connected and complete digital patient records across all pathways and care settings. Progress in e-health is very much necessary to unleash significant benefits for patients and healthcare professionals. We believe that there are clear building blocks to e-health and, in particular, a national e-prescribing service. Indeed, we have invested in some of these enablers. We want to help the HSE to move off the starting line, but we need partnership from it, with a clear commitment to e-health. This means clarity on targets, timelines and budget.
We believe that community pharmacy can and will play a vital role in the development and implementation of future healthcare reform, in line with Sláintecare, supporting people to stay healthy in their homes and communities for as long as possible. We need investment in community pharmacies to deliver services with a proven dividend in terms of value for money, improved patient outcomes and greater access to primary care for all of the population. It is time for the Government to engage with us on a positive agenda for change and to deliver convenient, accessible and cost-effective healthcare through a currently under-resourced and underutilised pharmacy profession.
I thank members sincerely for their attention. My colleagues and I will be pleased to answer whatever questions they may have.
Seán Crowe (Dublin South West, Sinn Fein)
Link to this: Individually | In context | Oireachtas source
I thank Mr. Twomey. I will now invite members to discuss matters with the witnesses, starting with Deputy Colm Burke.
Colm Burke (Cork North Central, Fine Gael)
Link to this: Individually | In context | Oireachtas source
I thank the witnesses for their presentations. I also thank them and pharmacies around the country for their contribution to dealing with the Covid issue and providing vaccinations, which was appreciated by everyone.
I will open with the issue of the chief pharmacist. It was stated that there was no one in the Department of Health with that level of expertise. The witnesses believe that a chief pharmacist should be appointed so that there could be much more co-ordination. Will they expand on how that could help the Department in dealing with the various challenges pharmacists face?
Ms Sharon Foley:
I am new to the IPU, but I have worked for more than 30 years in the health system. It is obvious that the role and potential of community pharmacy is not recognised in many policy and strategic documents. I have seen strategies for cancer, drugs and patient advocacy, yet there is none for pharmaceutical care. Being new to the sector, that is apparent.
Medicines are the most significant healthcare intervention. We spend approximately €2.3 billion per year on medications, a drugs bill that is constantly increasing. Medication harm accounts for 50% of the overall preventable harm in medical care. Recently, medicine shortages have emerged as a key risk to safe and effective healthcare, a matter that the committee has raised concerns about. It seems inconceivable that there is no strategic vision and direction for the pharmacy sector.
Colm Burke (Cork North Central, Fine Gael)
Link to this: Individually | In context | Oireachtas source
Is there engagement between the IPU and the Department on having a chief pharmacist?
Ms Sharon Foley:
We are engaging with the Department. The Minister has indicated that he would be interested in a strategy for pharmaceutical care. It is our opinion that that strategy should be driven by a chief pharmaceutical officer. This is what is happening in Wales, Scotland, England and Northern Ireland. In fact, they are going further and are already on their second or third strategies. In each of those places, the strategy is driven by a chief pharmaceutical officer. There is a Chief Medical Officer, a chief veterinary officer and a chief nursing officer. There is also a new chief health and social care professional officer. Why is there not a chief officer for pharmaceutical care?
Colm Burke (Cork North Central, Fine Gael)
Link to this: Individually | In context | Oireachtas source
The issue of access to contraception was raised. If there was a chief pharmacist, could many of the proposals in question be expedited?
Ms Sharon Foley:
Yes. A chief pharmaceutical officer would be responsible for pulling together a strategic vision and ensuring there was a voice for pharmacies at those tables where women's health, contraception and, indeed, minor ailments were being discussed. We are not alone in this belief. We have spoken to all of the State bodies and our colleagues in the HSE and the Department of Health. We have spoken to the universities and the pharmacy industry. They are all saying that we need a chief pharmaceutical officer.
Colm Burke (Cork North Central, Fine Gael)
Link to this: Individually | In context | Oireachtas source
Obviously, we are behind other countries in terms of access to contraception because of the regulations. As I understand it, the Minister could easily change those regulations in the morning.
Ms Kathy Maher:
Contraception being available free of charge to women was a welcome move and we were very happy to see it introduced last September, but we view access to contraception without prescription, in line with what the WHO said in 2019, as an important step in the healthcare of women. It can be done quickly using the Schedule 8 legislation, whereby we can have prescription-only medicine except when supplied and prescribed in accordance with protocol by pharmacists. It is important that we do-----
Colm Burke (Cork North Central, Fine Gael)
Link to this: Individually | In context | Oireachtas source
Why does Ms Maher believe there is a resistance within the Department to changing the regulation?
Ms Kathy Maher:
I do not necessarily believe there is a resistance within the Department. This would be a change of practice in Ireland and we are trying to drive the future of Irish pharmacy and healthcare for women forward. There is engagement. We see the introduction of free contraception for women as a positive first step, but we know that the only barrier is not financial. The barrier to access is a great barrier as well. We see pharmacists as the most accessible healthcare professional. We have longer hours. Women in some regions can access this service, for example, New Zealand, the UK and 19 states in the US. We are engaging with the Department and we want to drive this forward.
Colm Burke (Cork North Central, Fine Gael)
Link to this: Individually | In context | Oireachtas source
Where is the IPU in its engagement with the Department? Is this matter even on the agenda for discussion at the moment?
Ms Kathy Maher:
We had a positive meeting with the Minister, Deputy Stephen Donnelly, at the end of last year. We have raised this matter and received positive soundings that it was something that could be considered. A clinical group has been established within the HSE to look at the safety profile. Oral contraception is a safe medicine that has been available for 50 years. The WHO has stated that there is no clinical reason for it to be supplied on prescription only. The clinical group within the HSE is examining the matter. We are hoping for a positive outcome and to see the situation move quickly.
Colm Burke (Cork North Central, Fine Gael)
Link to this: Individually | In context | Oireachtas source
Another women's health issue has been raised with me, that of the drug Cariban. My understanding is that a pharmacy cannot dispense it even with a GP's prescription and that a consultant's prescription is required. Will the witnesses clarify this?
Dr. Susan O'Dwyer:
That medication needs to be prescribed in the initial instance by a consultant obstetrician. A woman has to go to hospital to see that consultant and then get the medication approved by him or her.
Subsequent GP prescriptions can be authorised and supplied but we believe this is a barrier to accessing that particular medication. We are talking about women in their first trimester who may not have ready access to a consultant and women with different abilities to pay having different access levels. The restriction to that consultant only and the requirement to have specific approval before the medication can be supplied through the pharmacy is a barrier and we would like this looked at.
Colm Burke (Cork North Central, Fine Gael)
Link to this: Individually | In context | Oireachtas source
At the moment, the person has to go to a consultant first and then a GP can prescribe the medication.
Colm Burke (Cork North Central, Fine Gael)
Link to this: Individually | In context | Oireachtas source
It is a problem at the moment because of the delay in the process of the patient getting access to a consultant and, in the meantime, there is a difficulty for the GP in managing the care.
Colm Burke (Cork North Central, Fine Gael)
Link to this: Individually | In context | Oireachtas source
Has this issue been raised? What is the problem that means the GP cannot prescribe it directly?
Dr. Susan O'Dwyer:
That is a question for the HSE. When new drugs are approved, sometimes they are given a restricted approval and certain conditions apply to that approval. By approval, I mean funding under community drug schemes. In this instance, the HSE has said that for this particular medication, consultant initiation is appropriate and that is the approval mechanism it has put in place.
Colm Burke (Cork North Central, Fine Gael)
Link to this: Individually | In context | Oireachtas source
On the engagement with the Department, is it regular engagement or is it hit and miss, in the sense that there might be consultation at the start of the year but it might not happen again for a substantial period? Is there any structure between the pharmacy union and the Department at this stage?
Ms Sharon Foley:
We engage very regularly on an officer-to-officer basis. We had a very positive meeting with the Minister at the end of last year, talking about where we wanted to move with pharmaceutical care. He certainly seemed to be very supportive of that. We would like to see a move towards action and implementation on developing a strategy for pharmaceutical care, in addition to some of the practical ideas and schemes that our president outlined.
Colm Burke (Cork North Central, Fine Gael)
Link to this: Individually | In context | Oireachtas source
Over the next six months, does Ms Foley anticipate progress with the Department on this issue?
Ms Sharon Foley:
They certainly indicated they are interested in moving on oral contraception, because it would massively increase access, particularly for younger women, new communities or Traveller women. They would see that as a mechanism to improve that access. However, until it is there and in place and we are engaging with them on the practicality of the scheme, I cannot answer that.
Colm Burke (Cork North Central, Fine Gael)
Link to this: Individually | In context | Oireachtas source
On the Department's response, the union has obviously raised the issue about the chief pharmacist. Has any indication been given by the Department on that issue?
Ms Sharon Foley:
Certainly, when we talk to the officers in the Department and people who understand pharmaceutical care, there is that agreement there. At a ministerial level, his preference is for a national strategy or action plan on pharmaceutical care. We do not mind. We will engage on that. We just want the opportunity to engage with the Department on developing a more joined-up strategy for pharmaceutical care. We feel it should be led by a chief pharmaceutical officer, as is the case in other countries. Where a chief pharmaceutical officer is in place in other countries, they are seeing massive strides and developments in pharmaceutical care. We were talking to colleagues from Scotland the other day. They are on their second, if not third, national strategy. They are really seeing pharmaceutical care develop and expand.
Colm Burke (Cork North Central, Fine Gael)
Link to this: Individually | In context | Oireachtas source
On the role of pharmacies and the minor ailment scheme issue, the IPU wants to see progress on that over the next six to eight months and engagement with the Department. Is the union satisfied that it could make progress on that? What can we as a health committee do to assist the union in making progress with the Department?
Ms Sharon Foley:
We are at quite an early stage of that progress. What the committee can do within its own remit is to ask questions of the Department and whether there has been any progress on a minor ailment scheme. We would like the opportunity to engage with the Department. It will not be me. It will be my colleagues who work in community pharmacies every day because they would know how this might work in practice and how it could be achieved at a community pharmacy level.
David Cullinane (Waterford, Sinn Fein)
Link to this: Individually | In context | Oireachtas source
I welcome all of our witnesses. I thank them for the detailed briefing note that they supplied to the committee. I also commend them on the recommendations they have made. I know many of us have engaged with them on an ongoing basis. The asks are very credible and they would add significant value to the health service. I commend the witnesses on that work. They have brought an excellent set of proposals to us as a committee.
I will begin with medicine shortages, which seems to be one of those issues in healthcare that is now becoming an all-year-round problem. I have engaged with many pharmacists on this issue over the past number of months. It hit a critical point before Christmas 2022 and into the early part of the new year. Other European countries have a serious shortage protocol in place. In his opening statement, Mr. Twomey did not go into much detail on what model he would like to see in place. Would it be something similar to that protocol or what would he like to see put in place? I imagine the problem is that when there is a shortage of a particular medicine, a person has to go back to a GP to get a prescription if an alternative medication is needed, which delays the process and so on. That is not good for patients, in the first instance, and it creates more work for GPs. What is the IPU's proposition to circumvent or deal with that? Would it be something like that protocol or something similar? Has the IPU made any proposals to the Department in that regard?
Mr. Dermot Twomey:
I thank the Deputy for the question. In terms of medicine shortages, one of the measures that has worked in other jurisdictions is the serious shortage protocol. Ultimately, as the Deputy outlined, it is about getting timely access to the medicine for patients when they need it. What we are looking for is similar to that which is in place in other jurisdictions, whereby the pharmacist would make - according to certain protocols and guidelines - a switch from one therapeutic molecule to another when a particular molecule is in short supply. The Deputy is 100% correct. It is not just a Christmas or winter issue. It is present all year. We are seeing that with many molecules at the moment. It was particularly highlighted during the recent respiratory syncytial virus, RSV, and influenza infections and that issue came to light. To answer the specific question, what we are looking for is that pharmacists would be empowered to make a clinical decision in their practice to switch from a particular molecule, such as to molecule B where molecule A or product A is not available, without recourse to the prescriber. This could be worked through protocols that can be developed. For example-----
David Cullinane (Waterford, Sinn Fein)
Link to this: Individually | In context | Oireachtas source
Would those protocols have, for example, guidelines that would have a second and a third line of a drug? The process would be highly regulated. Step-by-step guidelines would be available. Lots of protections would be in place as part of the process. That is the whole logic of having a protocol.
Mr. Dermot Twomey:
I agree 100%. If one looks at the prescribing of antibiotics, there are clear guidelines from the HSE with regard to what is the first-line, second-line and third-line antibiotics. We would very much advocate that we would work according to the protocols that would be set up.
David Cullinane (Waterford, Sinn Fein)
Link to this: Individually | In context | Oireachtas source
I refer to the issue of the chief pharmaceutical officer. Many of us on the committee championed the need for a health and social care professional, who would advocate for that sector, and we saw some movement on that issue. I am not against a chief pharmaceutical officer position being put in place. Is there any resistance to that in the HSE or the Department? We did meet with resistance on the health and social care professional officer position in the past and this was overcome. In the engagement the IPU has had with the Department, is there any reason the HSE would not want to do this? What has been the response from the Department in terms of the IPU's proposition on this issue?
Ms Sharon Foley:
The Deputy would have seen some of the resistance to the chief health and social care professional officer. It is a very slow journey to bring any new medical or allied health professional into the Departments. We have not engaged with the Department yet except with the Minister last November. His response at the time was that he wanted to see a strategic action plan. It is our belief that the minute that strategic action plan is developed, one would want an infrastructure to drive that. It is not just within the Department of Health. It is also with the HSE. When we engage with the Department of Health or the HSE, we have to go to several different areas and that makes it very complex. It is going to become even more complex when the HSE is divided into six regional health areas.
David Cullinane (Waterford, Sinn Fein)
Link to this: Individually | In context | Oireachtas source
Would the IPU see a value in having that officer position in place in advance of a national strategy?
Ms Sharon Foley:
Yes, we would. Just as the Deputy is talking about medicine shortages, just as we are talking about getting added value at community pharmacies and bringing that voice to the table, there is an awful lot coming at EU level around pharmaceutical care. That person and his or her team would be able to pull all of that together.
David Cullinane (Waterford, Sinn Fein)
Link to this: Individually | In context | Oireachtas source
If that officer position was in place, would that officer have a role in the State's policy on drug reimbursement or drug supply? That is a very cumbersome process, which this committee wants to look at as well. Would Ms Foley envisage the officer having a role in that space?
Ms Sharon Foley:
Absolutely. The shortage of medicine supply is a very complex supply chain issue. We do not have any easy answers but what we felt about the recent shortages was there was no one single entity that had that oversight of all parts of the process and could advise the Government accordingly.
David Cullinane (Waterford, Sinn Fein)
Link to this: Individually | In context | Oireachtas source
Okay. I want to move to the minor ailment scheme and to give the IPU most of the remaining time to outline how that would work. I see this as a no-brainer. It is something that I think could happen at pace and speed if the political will was there to make it happen. It should not have to be something that we have to wait for a national strategy to be in place. Obviously a national strategy can take time and there are lots of elements of what could be in a national strategy but look at what happened in winter, and ever during summer, in the pressure on our health service. GPs are under fierce pressure and anything we can do to take pressure away from primary care and general practice would be important. In the three minutes left, how can the minor ailment scheme work in practice? What benefits would it have for patients? How will it take pressure away from GPs at a time when we need more GPs and we need more general practice infrastructure? Anything we can do to relieve pressure would be good. Why might there be resistance to this? If it is a no-brainer, why has it not been done before now? Has the IPU been given any logic or reason for that?
I have put parliamentary questions down on this issue. An issue which the Department has flagged up to myself and to other Deputies who have raised this is that it sees a potential conflict between those who supply medicines and those who prescribe. What is the IPU's response to that?
Dr. Susan O'Dwyer:
A minor ailment is really just a condition that is minor in nature. It can resolve on its own so it is self-limiting, we often say. It can be relatively easily diagnosed in the community pharmacy setting and it can also be managed with either advice or treatments. A minor ailment scheme is where a patient would come to a community pharmacy. There would be an assessment of the symptoms and on foot of that assessment of symptoms you would always give advice, and self care advice, and there may be referral or there may be a supply of treatment. If you think about it as the assessment of the symptoms and the management of the condition that is being presented. This is something community pharmacists do every day. You make an assessment of those symptoms, you see if this is something that is mild and self-limiting and if it is not, if there are any red-flag symptoms then referral can happen.
Currently, we in pharmacy are restricted to the range of medicines that are currently available over the counter and we are also restricted to providing that service to people who have an ability to pay so it is not equitable in the number of people who can access the service and also the range of medicines. There are other medicines that are currently available on prescription that do treat minor self-limiting conditions and it would make sense to make those medications available. We spoke earlier about increasing access to contraception. It is the same mechanism, we believe. The medicinal products control and supply legislation has a Schedule 8 which is a list of medicines that can be supplied. They are prescription only but they can be supplied by a pharmacist in certain conditions.
Now, if someone has a medical card he or she will have to see a GP to get one of those over the counter medicines because it is not available to get free of charge in the community setting. Essentially, we would be talking about making that structured, having protocols in place and having very set criteria around when a treatment might be supplied and when it is not appropriate to be supplied. If you think about it as the assessment of symptoms, managing the condition and providing advice then you are taking a little bit away from the treatment and it is really about what is the most appropriate care for that patient.
David Cullinane (Waterford, Sinn Fein)
Link to this: Individually | In context | Oireachtas source
I should have mentioned Ms Sheena Mitchell who has done a lot of work in this area as well. I know that the IPU has engaged with her.
David Cullinane (Waterford, Sinn Fein)
Link to this: Individually | In context | Oireachtas source
I am not sure if she is a member of the IPU -----
David Cullinane (Waterford, Sinn Fein)
Link to this: Individually | In context | Oireachtas source
----- but she has done a lot of work and I want to commend her. Has the IPU engaged with her on the proposals?
Dr. Susan O'Dwyer:
Ms Mitchell would be able to talk about this from the front line. Every day she is seeing patients that are coming in. She knows what they need to treat their minor condition but she cannot give it to them either because they are a patient who does not have the ability to pay or because it is a medication that is not currently available. She will know that is taking time from GPs. A GP appointment is a precious point of time. There are different numbers of patients and only a certain number can access it. If you have a patient with uncomplicated athletes foot and one with uncontrolled hypertension, it is the one with uncontrolled hypertension who needs to be seen by the GP where the one with athletes foot could easily be seen in the community pharmacy. What you are doing is freeing up capacity. We estimate that you could free-up up to 1 million appointments in the GP sector just be increasing access to minor ailments treatment and assessments in community pharmacies. There will be 400,000 extra medical cards coming in April putting more pressure on that system. Increasing the numbers of points of access to care really will help to make the system a lot more equitable and convenient.
Róisín Shortall (Dublin North West, Social Democrats)
Link to this: Individually | In context | Oireachtas source
Everyone is welcome. I thank them for the presentation. I think Mr. Twomey was in touch with me about 12 years ago when I was in the Department of Health. At that stage he was way ahead of the curve and very innovative in the kinds of services he was providing from his premises in Cloyne. I remember being struck that it set out a very good potential model for the future of the pharmacy sector. Unfortunately, progress has been quite slow since then but Mr. Twomey was certainly putting it into practice.
At that time, I recall trying to get approval for pharmacists to provide the flu vaccination. I remember being shocked at the resistance there was to that. That seemed to be a no-brainer but there was resistance. This kind of thing is often regarded as business and losing business from other sectors. Thankfully we are at a stage when the flu vaccination is available locally in community pharmacies as was the Covid vaccination although there was also delays in making that available for pharmacists and, indeed, publicising that which was very regrettable.
Is there further potential for expanding access to vaccinations generally? Are there any other vaccine programmes that could be expanded in pharmacies?
Ms Kathy Maher:
I thank the Deputy for her kind words about the flu vaccine. I think I am old enough to have been around in 2011 or 2012 when we were trying to get the flu vaccine provision across the line for community pharmacies. It has been a really good example of how, when community pharmacies get involved in a scheme or project that we deliver to the nth degree for the benefit of our patients. We can see that when community pharmacies are delivering flu vaccines, not only do we increase our own supply but due to the publicity and the health promotion that we carry with that the general vaccine rate also increases in pharmacy and in general practice as well.
We are legislated to administer pneumococcal and shingles vaccines. We see huge scope there. We would like the Department of Health to remunerate pharmacists for that because we know there are cohorts of patients who need the shingles vaccine and the pneumococcal vaccine as a part of their healthcare and to avoid the complication that comes along with getting shingles, particularly in older age. We would like to see that as a reimbursed vaccine for pharmacists.
Róisín Shortall (Dublin North West, Social Democrats)
Link to this: Individually | In context | Oireachtas source
So it is not reimbursable at the moment? Why is that the case?
Dr. Susan O'Dwyer:
That is a decision for the Department in terms of funding under the national immunisation programme. It will make decisions on which particular vaccines should be reimbursed. To date, it has not made a decision around the shingles one. We would think that life-course vaccination is equally important to just the childhood vaccination programme so being able to fund that across the board makes sense.
Róisín Shortall (Dublin North West, Social Democrats)
Link to this: Individually | In context | Oireachtas source
Again, that is something for which there is no rationale, it seems. On the contraceptive programme, is there any downside to making that available through pharmacies? The IPU spoke about proper controls. What would that entail?
Ms Kathy Maher:
I refer back to the World Health Organization’s statement in 2019 that contraception is such a safe and effective medicine, with hormonal contraception around for more than 50 years, that it should be available to all women without the need for prescription. It is very safe and effective healthcare intervention. Since 2011 we have been delivering emergency hormonal contraception without prescription to the women of Ireland. At that point there may have been some fear that perhaps use would increase. That has been shown not to be the case. It is provided in a very safe and effective way using a structure protocol. Similarly, we had envisaged with emergency contraception, we can very often have the consultation to decide that is not an appropriate medicine for that woman and we refer her on to her GP or hospital where necessary. We see the same with contraception. Pharmacists are the medicines experts. This is our skill set. That is where we would see our role. Working with the National Women’s Council of Ireland, we know that the women of Ireland, and similarly across the world, have asked for this access.
The financial barrier is not always the greatest one. It is access to end services. Even in my practice, I see younger women, and even older women, who have had to take time off work and arrange childcare to try to access general practice and be able to have that consultation, when they can come into me perhaps on their way home from work, at weekends or on a late night. This is very easily done. To answer the Deputy's question, I do not see any downside. I think this is a very safe and effective healthcare intervention that we can give to the women of Ireland.
Róisín Shortall (Dublin North West, Social Democrats)
Link to this: Individually | In context | Oireachtas source
What is the Department's and the Minister's position on this now?
Ms Kathy Maher:
I believe the Department is very supportive. We would like to have further engagement. Ultimately, as well, we want to think about crisis pregnancies and try to avoid those coming forward. As Mr. Twomey said, today is International Women's Day and it is timely that we are having this conversation. I would like to see this situation change as a matter of urgency. The first step is to address the cost barrier for women. The free contraception scheme is currently for 17 to 26-year-olds and we will see this expand up to 30 come September. We would like to see this scheme provided to all women. We would also like to see the expansion of the availability of contraception without prescription. There may be some concern that long-acting reversible contraceptives, LARCs, are the gold standard, but we must come back to patient choice and let women have the choice. Let them come into us, as pharmacists and the most accessible healthcare professionals, and have the conversation. There will be no assumption that they will go for oral contraception. If we think a LARC is more accessible and beneficial for that patient, we will refer them on.
Róisín Shortall (Dublin North West, Social Democrats)
Link to this: Individually | In context | Oireachtas source
The committee might consider marking International Women's Day by endorsing this call and contacting the Minister to ask him to act on this. It is a significant matter for women of all ages, and young people in particular. Perhaps we might consider this later in the meeting. I think it would be a good move.
Returning to the national strategy and the action plan, I was surprised that there was not more in the presentation about chronic illness management. Is a lot of potential seen in this regard, given this is where things are at in respect of providing services at the lowest level of complexity and in the right place at the right time? Is there a lot of potential for the pharmacy sector to play a key role in this regard?
Dr. Susan O'Dwyer:
Yes, we believe there is. We have talked a little this morning about some of the skills pharmacists have, one of them being therapeutic substitution when we are talking about serious shortage protocols. Internationally, and if we look at Canada specifically, pharmacists also do things like therapeutic initiations or adaptations. For example, if someone is diagnosed with blood pressure issues, they may then get the initial diagnosis from the GP but be brought to the community pharmacy setting to undertake the initial management. We have systems in place where we can look at blood pressure management. We have pharmacies that do 24-hour blood pressure monitoring, etc., all the time. The readout is being received that is needed to see if a medicine is working appropriately for that patient. It means it is possible to respond to the results coming back from the objective assessment and to make dose adjustments. This is necessary because certain medications will work for one person, while different medications that might work better for another person. Pharmacists have this skill set. As Ms Maher said, pharmacists are medicines experts.
When we are looking at a chronic condition, therefore, one of the key interventions in this area involves medicines. I refer to medicines management and ensuring people are using them appropriately. There are examples like the New Medicines Service in the UK. When a medication is initiated, there is a structured intervention with the pharmacist. This supports the patient to stay on the medication, because sometimes it is hard for people to start on medications when they start them, especially for things like blood pressure issues. People might not have known about their blood pressure issues and then suddenly they are on a medication. They might start to have a few side effects and wonder if they really want the medication. I refer to people in this situation being able to discuss this with their pharmacist and tease it through. There is also the aspect of ongoing management and adherence to prescriptions, because staying on a medication and taking it properly and effectively is what will keep that medicine working very effectively as an intervention, but support is required to be able to take it. Pharmacists can play a major role in this area.
Róisín Shortall (Dublin North West, Social Democrats)
Link to this: Individually | In context | Oireachtas source
I note also in the briefing document, in terms of the various enablers referred to, that mention was made of the capacity in the sector and that this needs to be strengthened with additional third-level places. This is an aspect the committee is coming across the whole time. I refer to a lack of staff. In many cases, funding is available but staff cannot be recruited or are not available. This goes back to the lack of workforce planning at the Department or HSE level. There does not seem to be any comprehensive workforce plan at all in the health sector. As an organisation, has the IPU done any work on this aspect? I view this as something which is a key responsibility of the Department of Health, working in conjunction with the Department of Further and Higher Education, Research, Innovation and Science. Has the IPU done any work on trying to project forward what the needs are likely to be in terms of third-level places? I know many pharmacists, especially those that are local to me, talk about the difficulty in getting time off because they cannot get a locum pharmacist to come in. I wonder what the witnesses' experience of this context has been.
Mr. Dermot Twomey:
I thank the Deputy for that question. Just last year, we did a comprehensive study of community pharmacy across the board. It included not just our members but all pharmacists. We had approximately 1,100 respondents to the study. Several things came out of it. One of these was that at least 50% of pharmacists currently on the register in Ireland qualified abroad, predominantly in the UK. This very much shows us that as a country we are not training enough pharmacists to meet the needs of our population. Since Brexit, because of a number of issues, fewer pharmacists have come back from the UK and this is obviously an issue. Equally, fewer pharmacists are deciding to enter community pharmacy. Again, this is because of some of the points I raised earlier in terms of the bureaucracy and disproportional regulation. It is important, therefore, that we make the job and the career attractive for young pharmacists. We should also try and make it easy, including, as I mentioned earlier, by getting rid of legacy systems. We must also make it easier for non-EU pharmacists to qualify in this jurisdiction. We have seen with other professions how it can happen much faster. Ultimately, however, non-EU pharmacists must be able to get on the register, provided they have appropriate training and qualifications. This process is painfully slow. It is being looked at by our regulator, but it needs to happen much faster.
The Higher Education Authority is also looking at doubling the number of pharmacy places in the next few years. Obviously, however, this will take five or six years, at least, to happen. We think it is very important community pharmacists are empowered to do their job. If we look at the UK, all graduates qualifying there in pharmacy in 2026 will be prescribers. We are so far behind the curve here in that we are talking about minor ailments. My colleague, Dr. O'Dwyer, went into more of the clinical pathways. Even minor ailments and contraception would be a hell of a start, considering the low base we are currently at. Considering as well that Deputy Shortall and I conversed 12 or 13 years ago about managing patients in the community, very little has happened since. We must be ambitious. When we met the Minister in November, he spoke about the need to be disruptive and to look beyond the simple stuff. We must make a start and community pharmacy needs this, as do patients across Ireland.
Róisín Shortall (Dublin North West, Social Democrats)
Link to this: Individually | In context | Oireachtas source
Sure. At a time when there are such huge capacity problems in the health service, it does not make any sense not to maximise the potential of the pharmacy sector. I thank the witnesses.
Seán Crowe (Dublin South West, Sinn Fein)
Link to this: Individually | In context | Oireachtas source
I call Deputy Hourigan.
Neasa Hourigan (Dublin Central, Green Party)
Link to this: Individually | In context | Oireachtas source
I agree with Deputy Shortall's proposal, particularly concerning emergency contraception. This is the aspect I find frustrating. It is an emergency issue and we are adding on the trip to the GP and the expense associated. I am under the impression that 23 of 27 EU countries allow for some version of emergency contraception without a prescription. I thank the IPU for its briefing. It was very detailed, with many research papers cited. There was one from 2019 that I wish to ask about. I will not read out all the authors because there are too many of them, but it was a very interesting paper. One of the findings was that pharmacists showed great support for that kind of a scheme, but there was less support among physicians. Would the witnesses like to comment on this point?
Neasa Hourigan (Dublin Central, Green Party)
Link to this: Individually | In context | Oireachtas source
Okay.
Ms Kathy Maher:
One gap we have identified, however, is oral contraception in general being available by prescription only. I refer as well to the bridging aspect. We are talking about a trip back to the GP. If I provide a young woman, or an older woman, with emergency contraception, then part of my supply protocol is that I will have a conversation around ongoing contraception. I must then refer that person back to her prescriber to have another conversation. Even at this initial step, if I could provide bridging contraception at that point, it would mean an emergency may not happen again-----
Neasa Hourigan (Dublin Central, Green Party)
Link to this: Individually | In context | Oireachtas source
I return to the point of whether there is resistance from other groups in this regard. I am not referring to the Department or the HSE. Is there resistance within the other health providers?
Ms Kathy Maher:
When emergency medication was made available without prescription, there was a fear there would be increased use and perhaps even that advance rather than emergency supply would be sought.
Studies have shown, however, that increased use has not happened. It is being used appropriately and safely. We know from that experience there is no reason not to supply contraception without prescription. We know the safety profile is there.
Neasa Hourigan (Dublin Central, Green Party)
Link to this: Individually | In context | Oireachtas source
I am glad that the IPU continues to push for more services in community pharmacies and a right care, right time, right place model. I recognise that reimbursement to the pharmacies might be one factor, but I will return to the issue of locum rates for pharmacists, which are high. I understand there is competition for staff in the industry. Is the answer to that is higher education places and input from the Higher Education Authority, HEA? Is there anything we, as a committee, could push for now that would deal with the immediate need for further locum support?
Mr. Dermot Twomey:
There are a number of things we need, which were identified in our survey from last year. We are happy to share that survey with the committee after the meeting. We need more pharmacists working in community pharmacy. We also need more pharmacists per pharmacy. If we are looking to provide services, many pharmacies will need two or even three pharmacists to do so.
Locum pharmacists provide an essential service, particularly covering when people are on holidays or sick. One of the key points of concern is that if a pharmacist is working regularly as a locum and not based in a particular pharmacy and building a relationship with the patients and cohorts he or she serves, the level of care may well suffer. There are many excellent locums out there and they are an essential part of the chain. However, we think it is imperative that there are more pharmacists working on a regular basis within the community to provide impactful and meaningful healthcare.
Neasa Hourigan (Dublin Central, Green Party)
Link to this: Individually | In context | Oireachtas source
I will return to the strategic action plan and the lack thereof. A theme has arisen a number of times in our committee sessions. One of the enablers of change that the witnesses have outlined is an ICT system and working communication, if is not accurate to say "data sharing", with the HSE, which I assume is the largest issue. This has come up a number of times in the context of e-health records. There seems to be a lack of commitment and funding from the State to invest in a nationwide system. The witnesses might explain what such a system might look like. I presume it is envisaged that hospitals, primary healthcare centres and all of those places could communicate directly and in real time with pharmacies. Is that what it would look like? Representatives of the Prison Service were before the Joint Committee on Disability Matters. The Prison Service seems to have done an enormous amount of work and its representatives were describing something that is much more real time and effective in terms of access for the patients to their own information but also access to outside groups, such as pharmacists, sharing information and ensuring there is access to care at the right time, when people need it, in an accessible way. Will the witnesses outline what the system might look like if it were to be built around what their sector needs?
Dr. Susan O'Dwyer:
I will take that question. The Deputy is talking about access for patients to their electronic health records and for the healthcare professional, whether that is a hospital pharmacist, community pharmacist, GP or whoever it may be, to be able to access to a summary care record. A summary care record just details episodic periods of care. A medication list might be included, which would allow patients to see their own medication lists. It would also allow access for hospital pharmacists who are doing a medicines reconciliation or for community pharmacists, who need to know if things have changed when a patient comes out of hospital. If patients are seeing different providers, all the information would be in one place. That is important. To get to a place where there is an electronic health record, or even a national summary record, the building blocks need to be in place. One of the key building blocks is e-prescribing. We talk about the digital transfer of prescriptions, which we have at the moment, but we do not have e-prescribing. Under a proper e-prescribing system, the doctor would write a prescription which is coded. A code would be given to the patient so there is an identifier. There would also be a code for the drugs. There would be identifiers for those elements. That would then be transmitted to a national service, be it the cloud, if you want to describe it that way. It would be pushed to a national system. Patients could then go wherever they want. They would have free movement and could go to whatever pharmacy they want at whatever time. If the pharmacy they chose to go to initially was closed, they could go to another. They could go into that pharmacy and ask for their medication and their prescription to be filled. The pharmacist could then pull down that information, which would come into the system and be coded.
To go a step further, there would also be real-time eligibility if the system were linked to a national reimbursement system. All someone would ever need to see if a patient is eligible or approved for a certain medication would be the patient identifier and a medication identifier. That information would be linked into the national reimbursement system, which could tell the pharmacist in real time if a person is eligible. At the moment, there is a lot of red tape and administration needed to determine-----
Neasa Hourigan (Dublin Central, Green Party)
Link to this: Individually | In context | Oireachtas source
A member of my family is constantly being given forms at the pharmacy.
Dr. Susan O'Dwyer:
That is it. It adds delay and makes timely access difficult. It is important to get to that first step of e-prescribing. We have some enablers that can help the HSE to do that, such as the national health products catalogue. We would encourage the HSE to engage with us so we can speed up the timely implementation of that first key building block that is necessary to move us along the way.
Neasa Hourigan (Dublin Central, Green Party)
Link to this: Individually | In context | Oireachtas source
Can we unpack that a little? That response is useful. I am sorry if I am doing a very deep dive into this topic but I am trying to understand. When Dr. O'Dwyer says that the information could live in the cloud or there is some kind of national system, would that be run and owned by the HSE or the Department?
Neasa Hourigan (Dublin Central, Green Party)
Link to this: Individually | In context | Oireachtas source
Pharmacists would then feed into it.
Dr. Susan O'Dwyer:
Individual healthcare professionals would feed into it. The patients would have the choice. They could express a preference for a particular pharmacy and ask the relevant pharmacist to take the prescription and dispense it. That prescription would then come to the patient's local pharmacy to be dispensed. The idea would be that there would be access to that e-dispensation so that if that patient then goes into hospital, the hospital pharmacist can look at the information and see the patient's medication on the medication list.
Neasa Hourigan (Dublin Central, Green Party)
Link to this: Individually | In context | Oireachtas source
When we talk about a national e-prescribing service, would it be something for which the pharmacy sector could make a business case and look at what the funding and procurement process would be? It sounds to me like that is not the case. The strategy would be more that the pharmacy sector would require the HSE or the Department to take action.
Neasa Hourigan (Dublin Central, Green Party)
Link to this: Individually | In context | Oireachtas source
I am still at the stage of trying to understand all the component parts.
Ms Sharon Foley:
Because it would be a national system, it would have to be driven and owned by the HSE. We have been working to encourage and facilitate developments in ICT for many years. We are aware of the committee's most recent engagement. Progress has been very slow. What we need from the HSE is engagement and partnership, the use of tools we have already developed, such as the national medicinal product trial, as well as timelines, budgets and clarity on the key milestones so we can move to the next stage. As Mr. Twomey said, we are far behind some other countries. Estonia, for example, has brought in a whole new e-prescribing and e-health system.
Neasa Hourigan (Dublin Central, Green Party)
Link to this: Individually | In context | Oireachtas source
Estonia is ahead of us.
Neasa Hourigan (Dublin Central, Green Party)
Link to this: Individually | In context | Oireachtas source
Could the national e-prescribing service live independently of an e-health record system in general?
Neasa Hourigan (Dublin Central, Green Party)
Link to this: Individually | In context | Oireachtas source
Does that need to be there first?
Neasa Hourigan (Dublin Central, Green Party)
Link to this: Individually | In context | Oireachtas source
That is interesting and useful. I thank Dr. O'Dwyer.
Neasa Hourigan (Dublin Central, Green Party)
Link to this: Individually | In context | Oireachtas source
All the different building blocks.
Neasa Hourigan (Dublin Central, Green Party)
Link to this: Individually | In context | Oireachtas source
Are the witnesses aware of how far along we are in respect of e-prescribing?
Neasa Hourigan (Dublin Central, Green Party)
Link to this: Individually | In context | Oireachtas source
Does Dr. O'Dwyer know if there is a business case?
Gino Kenny (Dublin Mid West, People Before Profit Alliance)
Link to this: Individually | In context | Oireachtas source
I thank the witnesses for their statements. My first question relates to the pharmacy first model in Scotland. When was that implemented?
Gino Kenny (Dublin Mid West, People Before Profit Alliance)
Link to this: Individually | In context | Oireachtas source
Can pharmacists then prescribe certain medications in that environment?
Dr. Susan O'Dwyer:
They can. The Scottish model uses a structure called patient group directions to supply prescription-only products. That is for a certain cohort of patients that fulfil certain criteria. For example, pharmacists can give Aciclovir to treat shingles or fusidic acid to treat impetigo. A number of different specific conditions require prescription-only medicines that can be supplied by the pharmacist on foot of a structured consultation.
Gino Kenny (Dublin Mid West, People Before Profit Alliance)
Link to this: Individually | In context | Oireachtas source
Are there any circumstances in Ireland at present whereby the IPU can prescribe medications?
Dr. Susan O'Dwyer:
We talked about schedule 8 of the medicinal products control and supply regulations. That is where there are certain prescription-only products we can supply and-or administer. That is how pharmacists deliver flu, pneumococcal, shingles and Covid vaccines but also administer certain emergency medications, for example, Naloxone for somebody having an overdose or Glucon for somebody having a diabetic crisis. There is also Salbutamol for somebody having an asthma attack. These are medicines given in an emergency situation. Pharmacists can and do administer Adrenalin if somebody is having an anaphylactic reaction. That immediate and urgent emergency care is currently being delivered in a pharmacy setting through that structure.
Gino Kenny (Dublin Mid West, People Before Profit Alliance)
Link to this: Individually | In context | Oireachtas source
Okay. If somebody presents in that situation, you can-----
Gino Kenny (Dublin Mid West, People Before Profit Alliance)
Link to this: Individually | In context | Oireachtas source
-----administer that medication.
Gino Kenny (Dublin Mid West, People Before Profit Alliance)
Link to this: Individually | In context | Oireachtas source
That is interesting. The minor ailments scheme sounds like a brilliant idea. Other jurisdictions have implemented that and it seems to be a no-brainer. Has there been any resistance from GPs regarding the possible implementation of such a service?
Dr. Susan O'Dwyer:
Pharmacists and GPs work closely together in primary care and have a very good, strong working relationship on a local basis. The idea here relates to the patient. What we have are two healthcare professionals who will put the patient first. If the patient can be dealt with at the lowest level of complexity, if that is in the pharmacy, GPs can be and have been supportive of that. We will often refer patients to GPs. Equally, GPs will sometimes refer patients to pharmacies. It is about being able to work together with the patient as the core element. If pharmacists are embedded more into primary care networks, that interdisciplinary working in a primary care setting will become even stronger.
Gino Kenny (Dublin Mid West, People Before Profit Alliance)
Link to this: Individually | In context | Oireachtas source
Where did the IPU get the figure of 1 million appointments from? That is not a criticism; it is a great idea.
Dr. Susan O'Dwyer:
Work was done in 2016 and 2017. We can share that report. I do not have the exact detail on how all the figures were worked through but we can certainly submit that if necessary. We looked at the number and types of conditions being treated in a GP setting and the types of medications we know can be used to treat minor ailments. We looked at dispensing data in the State and could say this is the number of incidents of particular illnesses being treated in a GP setting. If we take that out of GPs' workload, we could free up 1 million consultations. We worked it out as something like 100 full-time equivalent hours' worth of capacity in that sector, just by introducing a service such as this.
Gino Kenny (Dublin Mid West, People Before Profit Alliance)
Link to this: Individually | In context | Oireachtas source
What would the classic example of that be?
Gino Kenny (Dublin Mid West, People Before Profit Alliance)
Link to this: Individually | In context | Oireachtas source
If a person goes to a GP and that interaction ends, and he or she goes to a pharmacist for minor ailments, what is the classic presentation of that, if there is one?
Dr. Susan O'Dwyer:
There are a range of different conditions. We estimated that something like 26 conditions are treated in Wales so there are quite a number. If we take the earlier example of uncomplicated athlete's foot, there is an over-the-counter cream you can get for that. You come to the pharmacist, who will assess your symptoms and say he or she knows you need that medication but, unfortunately, the pharmacist cannot give it to you because the item cannot be provided free of charge-----
Gino Kenny (Dublin Mid West, People Before Profit Alliance)
Link to this: Individually | In context | Oireachtas source
Even though it is right beside them.
Dr. Susan O'Dwyer:
It is beside us on the counter. We could reach back and pick it up but we cannot because the patient needs the piece the paper that states the doctor has written the prescription and, therefore, it is approved on the medical card and the pharmacist can supply it. The Deputy can imagine the time and effort it has taken for the patient to have to go off to see a doctor and come back.
Gino Kenny (Dublin Mid West, People Before Profit Alliance)
Link to this: Individually | In context | Oireachtas source
It seems ludicrous.
Gino Kenny (Dublin Mid West, People Before Profit Alliance)
Link to this: Individually | In context | Oireachtas source
Why has it not been changed?
Gino Kenny (Dublin Mid West, People Before Profit Alliance)
Link to this: Individually | In context | Oireachtas source
For something as rudimentary as that, it sounds like a ridiculous situation that somebody has to go to a GP.
Gino Kenny (Dublin Mid West, People Before Profit Alliance)
Link to this: Individually | In context | Oireachtas source
There must be resistance somewhere. This comes from different vested interests.
Mr. Dermot Twomey:
As we mentioned, it is about thinking outside the box, being agile, and looking at being disruptive. As Dr. O'Dwyer and my colleagues said, it is ultimately about patient care and lack of planning. In fairness to the Minister, during the meeting he certainly seemed very keen to move forward on some of these proposals. Colleagues who have been president of the IPU before me - Ms Maher was one a number of years ago - have heard similar words and platitudes. It is about action at this stage.
I will give a little more context on minor ailments. It is about equity of access. A person with money in his or her pocket is able to get a particular product. That individual can source the product and get it in the pharmacy whereas the person with a medical card has to recourse back to his or her GP. That is an inequitable system. Equally, as Dr. O'Dwyer mentioned, it is about expanding the scope of practice. There are a number of other conditions for which the products are currently prescription-only. It is about thinking big and moving on some of those and, as has been said, working under protocols. Very often, there may be scenarios where we will not supply a product. As another Deputy mentioned in respect of emergency contraception, we often do consultations where a product supply is not suitable and a patient is referred to a GP. We see that still being the case with regard to minor ailments.
Gino Kenny (Dublin Mid West, People Before Profit Alliance)
Link to this: Individually | In context | Oireachtas source
A prescription is not needed for the morning after pill. My final question is on contraception. Again, the interaction whereby a prescription is needed for that is kind of ludicrous. Are there any other states in Europe where a prescription is needed for a rudimentary medicine such as contraception?
Gino Kenny (Dublin Mid West, People Before Profit Alliance)
Link to this: Individually | In context | Oireachtas source
Does Ms Maher know which countries have this still?
Gino Kenny (Dublin Mid West, People Before Profit Alliance)
Link to this: Individually | In context | Oireachtas source
Yes.
Gino Kenny (Dublin Mid West, People Before Profit Alliance)
Link to this: Individually | In context | Oireachtas source
Over the counter.
Gino Kenny (Dublin Mid West, People Before Profit Alliance)
Link to this: Individually | In context | Oireachtas source
Okay. It would be interesting to see what countries still have this policy. I will be careful how I say this, but there might be historical reasons for that.
I am running out of time. My final question relates to the drug Cariban. I do not know whether the representatives are aware of this drug. Some people have contacted us on this issue. It seems convoluted that to obtain such a drug, which is effective in the treatment of acute nausea in pregnancy, women have to go - correct me if I am wrong - via their consultant. They get the prescription via the consultant, and subsequently get it via their GP but are not reimbursed immediately. It is making accessibility much more difficult than it should be. The Minister has put funding towards improving the accessibility of Cariban, but it seems a very arduous process for women to get this vital drug. Will the representatives comment on that?
Dr. Susan O'Dwyer:
We agree it is great that funding has been put forward but structures are in place with regard to the PCRS and the HSE that affect how that works in practice. Often, when new medicines are brought to the market, some specific restrictions will be put on their supply in terms of funding. That is to control spend in many cases. On Cariban, the structure that has been put in place means women have to go to a consultant in the first instance. The very first prescribing of Cariban needs to be consultant initiated. After that, patients can go to their GP and their second, third and subsequent prescriptions can be GP initiated if necessary. Once the initial approval is in place, the GP can follow on with that prescribing.
Patients can come to the pharmacy from the hospital, with consultant approval, if they are private patients. If they are medical card patients, they have to do that step where they go to their GP, get the drug written on the medical card prescription and then come to the pharmacy. There are many barriers along the way. There are barriers to access in lots of places. We welcome the funding for Cariban but the systems in place to realistically have it approved in practice, and women actually accessing it, put too many restrictions in place and delay access for those women.
Gino Kenny (Dublin Mid West, People Before Profit Alliance)
Link to this: Individually | In context | Oireachtas source
Is Cariban a non-licensed medicine?
Gino Kenny (Dublin Mid West, People Before Profit Alliance)
Link to this: Individually | In context | Oireachtas source
For acute nausea.
Gino Kenny (Dublin Mid West, People Before Profit Alliance)
Link to this: Individually | In context | Oireachtas source
I presume if it were licensed, there would not be this issue. Am I correct on that?
Dr. Susan O'Dwyer:
I do not think you can say that. It all depends on the HSE. The HSE is the one that makes decisions around how medicines are accessed.
We have plenty of licensed medicines in Ireland with similar restrictions in order to control access and make best use of the drugs budget. When we talk about administrative burden in pharmacy it is all of those different systems. Dispensing a prescription is not as simple as it used to be. Much of a pharmacist's time and attention is focused on the administrative aspect of whether they will get paid for an item whereas it should be focused on the clinical aspect of whether it is safe for the patient, whether it interacts with their other medications and that kind of thing.
Bernard Durkan (Kildare North, Fine Gael)
Link to this: Individually | In context | Oireachtas source
I welcome our guests and thank them for their comprehensive presentations and the information they made available to the committee. What are the most urgently required changes in legislation, practice or governance that might be introduced in the shortest possible time to improve the extent and availability of pharmacy services to the community?
Mr. Dermot Twomey:
I thank the Deputy for his question. As my colleagues have alluded to, probably the two areas that would make the most impact in the shortest term would be the ability to provide contraception without prescription and expanding the minor ailment triage scheme which allows pharmacy to deal with the least complicated cases in community pharmacy thereby freeing up general practice to deal with more complicated cases. I think people on the street would see it as a no-brainer as long as appropriate protocols are in place.
It is very important that there would be engagement on fees. As I mentioned earlier, by a June of this year the Minister needs to review the fees paid to community pharmacy. There has been no increase since 2008 and we have only seen decreases in that time. Fees are so important because in order for community pharmacy to provide these services we need to underpin it with a strong workforce and working team. That is why we need a realistic fee paid for the services and for dispensing. As my colleague Dr. O'Dwyer mentioned it has become more complicated. When I started 27 years ago, I could focus more on the clinical needs of the patient, whereas now my colleagues and I are increasingly focused on reimbursement approvals, which unfortunately is taking away from where we want to be.
Bernard Durkan (Kildare North, Fine Gael)
Link to this: Individually | In context | Oireachtas source
Regarding contraception services, have adequate measures been taken to protect the access to pharmacy premises? Can more be done? Has any action has been taken by others outside the system to discourage people or to highlight people's attendance? Anybody who attends a doctor, a pharmacist or any other body for that matter has the right to attend anonymously. They should not have to salute or kowtow to any other organisations outside once the law of the land has been observed. While people might say they have the right to protest, it is not to the extent that it impedes access to a service, whatever that service may be. I would like to hear the witnesses' comments on that.
I will follow that up with a question on emergency services and the degree to which pharmacists have seen the development of the contraception services in recent years with particular reference to the safety factor. One of the things we dealt with some years ago when the Bill was introduced was the need to ensure that early focus was put on the person who may have a need - a pregnant person with blood pressure problems or whatever the case may be - so that action was taken quickly rather than allow things to drift. Those are two questions for anybody.
Ms Kathy Maher:
I will respond to the Deputy's first question on contraception and how women access the service. Since November 2011, pharmacies have been required by law to have consultation space that is audibly and visually private within their premises. What happens in the consultation space stays confidential for that woman. When I bring a patient into my consultation room, nobody knows what my conversation is about. I gave this example to my colleagues this morning. Last Monday morning I had a conversation about a crisis pregnancy, a conversation about domestic violence and a conversation about emergency hormonal contraception. That was all before 11.30 a.m. last Monday morning. I know what happens within my consultation space. I provide the best pharmaceutical care to my patients, but I also know they are assured that it is a confidential space for them where they can engage with a healthcare professional.
We do not really come across any protesting or any barriers in that respect for women. We think that giving access to contraception for women's healthcare is vital in reducing barriers. As I said earlier, this is such a timely day to have this discussion. Access to care and access to contraception will encourage women to take ownership of their own health journey and be project managers in their own health journey and their own sexual health which is really important. Pharmacists play a key role in that.
Bernard Durkan (Kildare North, Fine Gael)
Link to this: Individually | In context | Oireachtas source
I think there were two questions in that. I can introduce another one.
Ms Kathy Maher:
My colleague Dr. O'Dwyer will also answer. Over the past 20 years the need for the emergency services we have provided within our community pharmacy has exponentially increased. On multiple occasions have had to administer emergency salbutamol for an emergency asthma attack, or emergency adrenaline injections for anaphylactic reactions among children and adults in our consultation rooms. By having the resources, facilities and premises which are up to a certain standard we can provide that care in our community. I have a rural pharmacy and I know that I provide a significant level of emergency care to my patients.
Bernard Durkan (Kildare North, Fine Gael)
Link to this: Individually | In context | Oireachtas source
My next question is about attracting and retaining pharmacists for the future. What action are the organisations represented here taking? We have a rapidly increasing population and there is an obvious need to plan for the future. How much of that planning is taking place now? Do pharmacists have adequate plans in place to meet the challenges of the future?
Mr. Dermot Twomey:
There are a number of points here. One of the key things is that the job and role of community pharmacy must remain attractive for community pharmacists and their teams - the technicians and people who want to work in community pharmacy. It is a very rewarding role. However, as I mentioned earlier, unfortunately the job is being underpinned by an enormous amount of bureaucracy, paperwork and rules. Young community pharmacists are voting with their feet and deciding that it is not for them in the long term. Ultimately the Irish Pharmacy Union, as an organisation, in collaboration with the Department and the HSE, wants to ensure that money is used in the correct proportion based on the budget. However, we need to move forward with some of the legacy systems that are there and make the role much more attractive and easier so that people are not coming home stressed from working in community pharmacy.
As we said earlier, it is important that we train more graduates. Currently we are not training a sufficient number. More than 50% of those on the current register trained in the UK. That is something the Higher Education Authority is looking at. Ultimately it is about expanding the scope of practice and allowing pharmacists to do more with their clinical judgment. That is what young pharmacists tell us they want to do, reducing the bureaucracy while understanding there is a fiduciary responsibility from the State. Ultimately the public vote with their feet by coming to us. They consistently identify us as one of the most trusted professions. They want us to do more. We need to remove the blockages and move things forward.
Bernard Durkan (Kildare North, Fine Gael)
Link to this: Individually | In context | Oireachtas source
To what extent are pharmacies in ongoing digital contact with hospitals, GP practices etc. with a view to ensuring the comprehensive availability of services and sufficient dialogue between all those providing services?
Dr. Susan O'Dwyer:
While we are in constant dialogue, it is not in a digital format. Regarding GPs, there is a digital transfer of prescriptions via Healthmail but that is an e-mail system. We will inform a GP, for example, if we have given a flu vaccination and that is through another digital system.
There are lots of systems we interact with. We speak with colleagues in hospital, as a prescription may need to be queried. One makes an intervention, and may have to speak with a hospital pharmacist to get clarification on the medication being taken by a patient. However, most of those conversations are still happening over the phone. We spoke earlier about some of the building blocks we need to see in that ITC space, in particular an e-prescribing system to allow the building of electronic health records within national summary care records.
Bernard Durkan (Kildare North, Fine Gael)
Link to this: Individually | In context | Oireachtas source
My final question is on reimbursements, which is a favourite phrase that comes across our desks regularly. What experiences have the witnesses had that cause them difficulties with reimbursement in the course of their work? What areas are most prominent? We know where they are, but it is no harm to be reminded again.
Ms Kathy Maher:
As a practising pharmacist I sometimes find it difficult when I have a patient in front of me and I do not know whether they will be approved for the medicine prescribed for them on that day. I would love a system where we have real-time eligibility. As Dr. O'Dwyer has spoken about, when we really get e-prescribing and move further along that digital pathway, we can have a system where I will know if a patient standing in front of me with a prescription is eligible for that medicine under a State drugs scheme. We have to reach a point where we reimburse fairly as a sector and as a profession. Mr. Twomey earlier alluded to our fees being reduced by 21% since 2008. We have not had a fee increase; we have had a fee reduction. The average fee for dispensing per item was around €6 in 2008. The average fee now sits at around €4.74. To enable us to deliver all we can and all we have spoken about today, and to enable our future vision for pharmacy and subsequent positive patient outcomes, we need to make sure we are fairly remunerated as a sector and as a profession. We are committed to engaging with the Minister and the Department of Health. They must review our fees by the end of June 2023. We are ready, willing and able to have that engagement and conversation with the Department.
Martin Conway (Fine Gael)
Link to this: Individually | In context | Oireachtas source
I thank the witnesses for attending today, for their detailed presentations and for the phenomenal work they have done in recent years to support our society during the pandemic. I will start with one specific question. Last week, a report was launched on advancing the prevention agenda for cardiovascular disease in Ireland. One of the key recommendations was on screening. It seems that screening for a lot of cardiovascular diseases is something that can be done relatively simply with a stethoscope. Is that something pharmacists around the country would be interested in doing? What is the witnesses' view of that type of screening, and would they be prepared to participate in such a screening programme?
Dr. Susan O'Dwyer:
The short answer is "Yes". Pharmacists are already working in this space. Almost every pharmacy will take your blood pressure. However, 24-hour blood pressure assessments are being done in practice. There are pharmacies that include detection of atrial fibrillation as part of that assessment. Those people are then referred to their GP either to initiate therapy or to adjust their therapy if the readings suggest that. A pharmacy is an accessible location. We have the ability to do this and we are doing it. Unfortunately, it is not equitable. Currently those services are only provided to people with the ability to pay for them. If they were provided to anyone on the basis of clinical need, that would probably improve access and the rate of detection and hence improve outcomes.
Martin Conway (Fine Gael)
Link to this: Individually | In context | Oireachtas source
Roughly how many pharmacies provide the flu vaccine?
Martin Conway (Fine Gael)
Link to this: Individually | In context | Oireachtas source
Are many other vaccines being provided? If there are not, should pharmacists be providing more? Is there any engagement with the Department to scale up provision of vaccine facilities and services within pharmacists?
Dr. Susan O'Dwyer:
Pharmacists have demonstrated themselves to be very able and competent in this field. We deliver about 30% of the total flu vaccinations in the country. We have delivered 11% of the Covid vaccinations. Now that we are in a more business-as-usual season, we are at 25% or 26%. I should not be quoted on those exact figures, but they are in that region. Pharmacists are able, competent and capable, but patients are choosing it as they see it as an access point. They trust it. They come back year after year. It is something we have proven to be safe. It is governed well, and we have very clear structures in place. It is very easy in our mind. We have the skill for administration of the medication. There is some clinical information one will need, that pharmacists already know about because we are medicine experts. That is our day to day. We believe there are more vaccines that could be reimbursed, but also more vaccines that could be made available through Schedule 8 to the medicinal products control and supply legislation.
Martin Conway (Fine Gael)
Link to this: Individually | In context | Oireachtas source
What about the HPV vaccine? Are any pharmacists providing that?
Dr. Susan O'Dwyer:
We are restricted to providing those medications only when presented with a prescription with a written instruction from a doctor that says "please administer this vaccine." In that situation it can be done. However, it is not the same as a flu vaccine. If one wants to get a flu vaccine from a pharmacy, one can walk in and get it. HPV is not included in that Schedule, but we see that as a vaccine that could definitely be added to the Schedule and delivered in pharmacies.
Martin Conway (Fine Gael)
Link to this: Individually | In context | Oireachtas source
It is a no-brainer. I watched Dr. O'Dwyer's earlier engagements from my office about the chief pharmaceutical officer in the Department of Health. It is mind-boggling that this position has not been created. It would certainly help to advocate within the Department for the kinds of areas where pharmacists could easily scale up and assist.
I have another question. A lot of primary care centres are opening around the country. Some of these have pharmacists. Is there any engagement or discussion within the IPU about pharmacists in primary care centres taking business away from established pharmacists in particular towns? Is there an IPU policy position on that? What is its view?
Ms Kathy Maher:
It is ultimately about patient choice. Patients need to be comfortable with their own locality, with their own pharmacist and with whoever provides them with the best care. We have seen through our behaviour and attitudes work that patients do not always choose for a particular reason. They tend to go by their locality, their service and what is closest to them. We know that 85% of the country lives within 5 km of a pharmacy, and 50% lives within 1 km of one. Even when there is an out-of-town pharmacy, patients tend to go where they choose to have the best care and where they maybe have built a relationship with the pharmacy over many years. That is where they tend to go.
Martin Conway (Fine Gael)
Link to this: Individually | In context | Oireachtas source
Are there any figures for the number of primary care centres with pharmacists?
Martin Conway (Fine Gael)
Link to this: Individually | In context | Oireachtas source
I am interested, because primary care centres are great and very welcome. However, sometimes they displace other businesses. For example there might be two well-established pharmacists in a town when a new primary care centre opens, which includes a pharmacist. It is quite unfair and I think the IPU should take a position and lobby on behalf of the existing pharmacists. In some cases there is a need for a pharmacist, but in others there is absolutely none. I will leave that with Ms Maher.
I have a final question. Does the IPU encourage pharmacists in particular counties to work together to provide out-of-hours services, for example on Sundays? Are there any protocols or discussions, or is it left as a local solution? We know people get sick at weekends as well as during the week. It can be very difficult, particularly on a Sunday or a bank holiday Monday to find an open pharmacy, particularly in rural areas. Is there any consideration of that dilemma for people, within the union structure?
Mr. Dermot Twomey:
I thank the Senator for his question. For out-of-hours and weekend services, many towns would historically have had a rota arrangement between a number of pharmacies to provide those services, particularly on bank holiday weekends and Sundays, etc. In the past 25 or 30 years we have seen a proliferation of pharmacies providing extended hours in certain areas. That has come into conflict with rota arrangements. Rotas are very much local. Over time, because of a particular pharmacy providing a late-night service, the rota fell by the wayside because there was no particular need for it.
What we found in the past year or two is that it has come back a bit. The difficulty we mentioned earlier in terms of having enough qualified pharmacists to work in community pharmacy has led to a shortening of opening hours. Many pharmacies, including some of the late-night ones, have pulled back, which, unfortunately, is probably having an effect at a local level. As an organisation, we are always amenable to discussing issues around that with Government and the Department. It is something we can certainly discuss. Providing those services would have a cost and that cost would need to be discussed.
Martin Conway (Fine Gael)
Link to this: Individually | In context | Oireachtas source
Is the serious challenge with rural GPs with some villages and towns ending up with no GP having a serious impact on the local pharmacy? Have pharmacies had to close as a direct result of the GP service no longer being available?
Ms Kathy Maher:
We can safely say that pharmacies are providing an exemplary service in all areas but especially those areas with no GP practice or where a GP has reduced hours or has had to leave the area. When we look at April or May, when another 400,000 medical cards come on stream and the value in the additional services we have talked about this morning, that is where it really comes into play when it eases on existing GP services. We know GP services are under pressure, with a number of GPs coming close to retirement. By increasing the scope of pharmacy practice, we can help alleviate a lot of that pressure.
Martin Conway (Fine Gael)
Link to this: Individually | In context | Oireachtas source
Is there a challenge with pharmacists in rural areas in terms of their survival in the first instance and with younger pharmacists not choosing to live in rural areas? Is a challenge coming down the tracks for rural pharmacy?
Ms Kathy Maher:
There is a challenge. I have a pharmacy in County Meath and have been there for 24 years. I have seen various stages of growth and decline. The challenge is in all areas. It is in our remuneration, our workforce and our capacity to practice and deliver the service I want to deliver given the bureaucracy, for example, having 13 tabs open just to see if a patient is eligible for a particular medicine. All of that is a challenge in terms of trying to drive the sector and profession forward and still maintain a clinical job satisfaction at the end of the day when I have served my patients. Both rural and urban pharmacies need us to make sure pharmacy has a strategic vision and plan, which will best serve Irish patients.
Maria Byrne (Fine Gael)
Link to this: Individually | In context | Oireachtas source
I was speaking earlier in the Seanad so I was not here for the presentations but I did read Mr. Twomey's opening statement. There are three pharmacists and a pharmaceutical assistant in my family so I regularly hear about the issues facing pharmacists. I pay tribute to pharmacists across Ireland for their supporting role and work during Covid because pharmacies were the only places open almost every day. Some pharmacies were open seven days a week. When people could not get access to GPs or hospitals, they relied on their community pharmacists so they deserve a big "thank you" for that. The role they played was vital.
I was thinking about the minor ailments scheme or triage. Some people might present to a pharmacist and discover they need a bottle of Gaviscon. They might go to their doctor to get the prescription and then have to come back to the pharmacist to dispense it because they have a medical card. Is there any way in which pharmacists could be given prescribing rights for minor treatments? I know it would require legislative change. I think this is what the witnesses are saying regarding triage and the minor ailments scheme because I have seen people who have gone to the pharmacist, discovered they needed something minor, looked for a doctor's appointment, were facilitated by the doctor, took up the doctor's time and then had to come back to the pharmacist so they could get the medicine on their prescription.
Regarding the shortage of medicines, I see with one or two older people I help who live near me that they might get one brand this month and another the next month. It is very confusing for older people. Have the witnesses any ideas how this can be addressed? I understand that sometimes the brand they are used to getting might not be available. A neighbour of mine rang me up one day asking me to come down because they did not have a clue what was in the product. I am not a pharmacist but I had to look for the same word on both packages to see if it was that medicine.
I support the witnesses' call for a chief pharmaceutical officer. We have a chief dental officer. Have the witnesses had any discussions with the Department and has it been receptive or are things going nowhere?
Dr. Susan O'Dwyer:
I will start with the minor ailments scheme. The Senator summed it up very well. There are some key issues there. It is the range of products that are available. More could be made available because there are products that are currently restricted to prescription only that are used in the treatment of conditions that are relatively minor, can be diagnosed in the pharmacy setting and treated safely by the pharmacist under protocol. There are also access issues for people with medical cards. There are products for which they do not need a prescription but they need a code or drug code and these are only supplied to patients with medical cards on foot of a prescription because that is the structure in place. Perhaps we could look at some of those HSE structures around direct reimbursement of pharmacies for that assessment and provision of treatment. That would make the service more equitable and more expansive to allow a greater range of minor conditions to be treated in a pharmacy and more access points for people to be seen quickly. That would free up capacity in the GP sector to allow GPs deal with more complex cases. Mr. Twomey might address the question about the shortage of medicines.
Mr. Dermot Twomey:
We discussed the serious shortage protocol. We think that would be key to helping pharmacists make those decisions where they need to be made. Regarding some of the Senator's points about the brands and the different products, it is outside our control. It is upstream of where we are. Some things that could be done at HSE level include allowing temporary medical card or GMS codes for certain products in a proactive fashion so that when certain products are short, the patient is not encumbered with a financial charge to procure the product that is available. We are looking for the HSE to be proactive and look in advance to see what codes are required on a temporary basis. We think this is very important.
When some products go short, a branded product might be the only one available and sometimes co-payments are required for the patient to pay for those particular brands. We think it important these co-payments are waived where there are serious shortages.
Ms Sharon Foley:
We think the post of chief pharmaceutical officer would bring a lot of that proactivity into the system. We would like somebody to be employed at a particular level. If you look at the CNO and the CMO, they are at a level where they are able to influence the Department of Health, which is particularly important. We have talked to all colleagues working as pharmacists or working in pharmaceutical care, including hospital pharmacists, industry, pharmacists in the HSE, the Department and universities. All of them have said there is a need for a chief pharmaceutical officer and a national strategy or action plan on pharmaceutical care. It will not happen just because we want it to happen. We raised it with the Minister last November and he certainly saw the need for greater concerted joined-up activity around pharmaceutical care, but I do not think the Department is in a place where it will appoint a chief pharmaceutical officer. A member of the committee referred to the length of time it took to get the chief health and social care professional officer. We hope it would not take that long. Members can see today from what my colleagues have said that there are a lot of quicks wins in the system, but equally there are many very significant challenges coming down the road around medicine shortages and the cost of medicines.
We need to work together and to develop concerted, joined-up activity to realise the value of community pharmacists. To bring the committee back to something one of our colleagues said, in 2026, which is only three years away, all pharmacists qualifying in the UK will be prescribers. That is where they are. Where we are is so far behind, we really need to get up to speed and get in line with our international colleagues.
Maria Byrne (Fine Gael)
Link to this: Individually | In context | Oireachtas source
I think it was Mr. Twomey who referred to not enough people qualifying in Ireland and then many ending up going to the UK. The Minister for Further and Higher Education, Research, Innovation and Science put out a call to the various universities to express interest in providing courses in that regard. I am not sure if pharmacy was included in that but I know that medicine, nursing and veterinary medicine were. Has the IPU had any engagement with any of the universities on that? UL put in an application in respect of veterinary medicine and engaged and collaborated with the local veterinary practices on its application. Has the IPU had any linkages with any of the universities currently teaching pharmacy or any new college interested in expanding?
Ms Sharon Foley:
We certainly have, and we know from the HEA that it has received expressions of interest to expand current pharmacy courses. Those expressions of interest are with the HEA and it will make a decision by the end of this month. If there is to be a new college, our preference in the immediate term, having worked with the universities, would be to expand the number of places on the current courses because they have the labs, the universities and the curriculum. That is not to say there would not be another university, but there is an awful lot of work involved in developing a new course. What we would like to see, therefore, particularly from the HEA, is that it is actioned and those increased number of places are active from next September.
To comment on the Brexit piece, because many of the pharmacists were trained in the UK, that channel has effectively dried up because students cannot afford to train there any more. It is not like there is a bank of pharmacists in the UK to come back; there is not. Therefore, we have to address this workforce shortage for the next few years fairly quickly, starting next September.
Maria Byrne (Fine Gael)
Link to this: Individually | In context | Oireachtas source
I have been working with a number of pharmacies in my area and they have had to bring in pharmacists from abroad who may have qualified in non-European countries and there is an issue with the granting of permits. While a number of them have been successful, has there been much engagement with the IPU and enterprise on that? I know of one application where the person involved is approaching the final week in respect of refusal. Trying to get it sorted is so frustrating. Do the witnesses have any comments on that? It is a big issue for many pharmacists.
As for people qualifying, are pharmacists working in Ireland first or going abroad first and then coming back?
Dr. Susan O'Dwyer:
I will speak about what we call the third country qualification route, that is, pharmacists outside of the EU. They need to come to Ireland and do what is called an adaptation period, that is, work in a pharmacy under the supervision of a pharmacist. That adaptation period can be anything from six months to two years; it depends. It is a process the Pharmaceutical Society of Ireland takes charge of. It is reviewing that process at the moment, and we are advocating at all times for that not only to be sped up but also to be facilitated, as the Senator mentioned, with visas. It is quite difficult for those applicants to get visas because they do not fit into one or the other category. They are not qualified professionals in the eyes of the State because they are undergoing the adaptation period but, equally, they are not students because they are qualified as pharmacists in their home countries, so there is that disparity. Our call is for that process to be expedited, for the relevant Departments to look at the visas and work with us to see that these are pharmacists. They are on the critical skills list, so we need these skills in our country now and we need to be able to move that process on and make it work faster and better for the people involved.
Seán Crowe (Dublin South West, Sinn Fein)
Link to this: Individually | In context | Oireachtas source
I think we would all accept the idea of an expanded role for Irish pharmacists in this area. The frustrating thing for us, especially as Members but also as a committee, is that every week we hear this is possibly under review and so on. We have heard a number of possible ways of moving forward today and we have heard that the matter is under review. I believe there is a general consensus among the members - certainly, it has been expressed - that we would look for an update from the Department on the minor illness scheme. There is a motion on oral contraceptives that I will put to the committee at the end of the meeting. Is there anything additional we could do as a committee about the supply bottlenecks? Dr. O'Dwyer mentioned medicines supply shortages and therapeutic substitution of medicines. I presume that means that if a particular brand is not available, it is just replaced with another. Mr. Twomey talked about singular molecules in particular branded medicines. I am coming at this as a layman.
Mr. Dermot Twomey:
I thank the Chair for the question. It is more that pharmacists are entitled to switch between a brand and a generic. With therapeutic substitution, we are talking about moving from one medicine to a different medicine. That would require the legislative change we are talking about. Therefore, it is not as simple as going to a different brand if one brand is not available. This is a different entity itself. We are talking about what is called a serious shortage protocol, which is being used in the UK. For example, in the UK, a particular medicine, Calvepen, which is an antibiotic, was used for infections and sore throats over the winter period. That was not available, so the serious shortage protocol allowed amoxicillin to be used first line. It is similar to penicillin but a different antibiotic. That would require legislative change.
Seán Crowe (Dublin South West, Sinn Fein)
Link to this: Individually | In context | Oireachtas source
To some extent there are a lot of regulations, even in respect of contraception, so it would possibly mean deregulation in some areas in that regard. Is that what is being suggested here?
Dr. Susan O'Dwyer:
I think we are looking at amendments to certain legislation. It is a matter of recognising that pharmacists have the skill set to do therapeutic substitution. When therapeutic substitution happens in practice, a pharmacist and a doctor will have a conversation about the patient being prescribed a specific agent for the particular condition and what we can give to do the same thing to treat the same condition. Often it is the pharmacist who makes that decision, but he or she works in conjunction with the medical practitioner, be that in a hospital or in the community. The skill set is there, but it is just a matter of the enabling legislation. At the moment that can be done under emergency supply legislation, but that is quite restrictive in terms of the quantity of medication that can be given, when it can be given and the rules that apply. It is just a matter of looking at whether there are any other ways in which that legislation can be tweaked slightly to make it just a little more all-encompassing.
The serious shortage protocol could be done under that legislation in that, with the serious shortage protocol, the clue is in the name. It is in use only when there is a serious shortage. That means there is none of the particular medication in the country to treat the patients who need to be treated with it, but there is an alternative, the pharmacists know what it is, we have a protocol and we can work through it. That could be time limited. It could be governed quite strictly as to what that would be. It is just a matter of the introduction of it. There are tweaks that can be made.
As for minor ailments and contraception, we are talking about something relatively straightforward. In fact, it has been done on numerous occasions through the Covid-19 pandemic. Whenever there is a new Covid-19 vaccine or an indication for a vaccine, those adjustments are made within Schedule 8. That is a very easy and quick process, I believe. Maybe it is easy for me to say that, but that is one of the pieces or the facilitators we think could bring change quite quickly.
Seán Crowe (Dublin South West, Sinn Fein)
Link to this: Individually | In context | Oireachtas source
As for the expanded role of the pharmacist, the witnesses gave some examples of other jurisdictions. Wales, Scotland and so on were mentioned. Was there pushback in those jurisdictions and, if so, where did it come from? Will there be pushback from, say, the medical profession in Ireland if we talk about expanded roles? Is there an inertia within the Department such that it says it is sympathetic and is listening to what the witnesses are saying but it is not building on-----
Ms Sharon Foley:
I think there is a mixture of all of that. If we look at other countries like Canada, and at Scotland and Wales, they are on a journey. Some of their expansion and development has happened over the last 20 or 30 years, so change happens slowly. As I said earlier, at this stage, we are so far behind that we need to try to speed up. There is a huge role for this committee in asking the right questions, in keeping the pressure and attention on it and to keep naming the need for a national pharmaceutical strategy and the development of some of the ideas we have shown. There will always be some levels of resistance because health systems in general resist change. It has to do with power and where things move. Other countries have shown it can be done and it certainly benefits the citizens of those countries, so it should be done.
Seán Crowe (Dublin South West, Sinn Fein)
Link to this: Individually | In context | Oireachtas source
There is a difficulty when someone goes to the pharmacy and it does not have their particular medication. In some cases, people might have to go back to their doctor. I presume that in some cases there is a charge involved in that. If a prescription is changed, are there charges? Is there an additional charge for the poor individual who cannot get access to that particular item or one similar?
Mr. Dermot Twomey:
There are not additional charges in that case. Unfortunately, the pharmacist is doing what they can for the patient, but it is time and resource intensive and that is the issue. If we join all the dots with our conversations today, we are trying to make healthcare more accessible for the patients, reduce the bureaucracy and improve health outcomes. For example, in the therapeutic substitution which my colleague mentioned, rather than have those steps, going back to the doctor, the patient waiting or the patient coming back later, the pharmacist would make that change under the serious shortage protocol.
With the minor ailment-type scheme we spoke about, if a person presents in the pharmacy with a simple skin infection, athlete's foot or something similar, we can deal with it without referring them to the GP. Regarding contraception for females, as Ms Maher alluded to, it is available in her pharmacy late in the evenings or at weekends. Young females may be working and may not be available to attend the GP during the week. It is all about making it accessible. We would like this committee to look at how the amendments to Schedule 8 can be done in order to move things forward. We have shown not just nationally but internationally that every time pharmacy has been involved in a new service, it has been a roaring success. This has been proven with vaccination and with any of the other services we have provided. Getting out of the starting blocks is the key point. The community pharmacy sector is willing and able, and very much wanting to get out of the starting blocks.
Seán Crowe (Dublin South West, Sinn Fein)
Link to this: Individually | In context | Oireachtas source
It was mentioned that 1 million appointments could be freed up by utilising the existing infrastructure of community pharmacists. Are the witnesses worried that people with minor ailments and, indeed, some more serious cases might find themselves walking through pharmacy doors? Are pharmacists up for that challenge?
Dr. Susan O'Dwyer:
Yes. People come in at present. Pharmacists are trained to do an assessment of the symptoms they are presenting with to see if there are any particular red flags or anything that needs more urgent attention or more complex intervention, whether that be with the GP or in the secondary care setting. It is all about doing the assessment, the triage and making sure the patient gets the right care in the right place. That may well be in the pharmacy, but if not, the pharmacy will refer the person to the right place.
Seán Crowe (Dublin South West, Sinn Fein)
Link to this: Individually | In context | Oireachtas source
The Ipsos MRBI survey on the most trusted healthcare providers was mentioned. That is reflected here. If the general public feel that pharmacists can be trusted, the politicians, certainly those in this room, would agree the system needs to be expanded. It is a matter of us collectively putting our heads together and asking some of those questions that need to be asked if there is clearly a shortage of places within the system. We need to ask the Minister for Further and Higher Education, Research, Innovation and Science about that. There are a number of questions that we, as a committee, can ask to move the issue along.
Colm Burke (Cork North Central, Fine Gael)
Link to this: Individually | In context | Oireachtas source
What I am concerned about is that we had a very good presentation this morning and I would hate that it would be lost with just a presentation and questions. As a committee, we should formally write to the Department of Health looking for answers to those questions. The next time the Department of Health and the HSE are in, we could have time set aside to deal with this particular part of the issue. I am not sure what way we could do this, but the committee needs to follow this meeting up with something constructive. The proposals have been very constructive. It is about improving healthcare. It is about the committee trying to get the Department of Health to move on the issues. We need to do a follow up on this.
Martin Conway (Fine Gael)
Link to this: Individually | In context | Oireachtas source
We should now engage in a formal process with the Department.
Seán Crowe (Dublin South West, Sinn Fein)
Link to this: Individually | In context | Oireachtas source
This is the first time I have heard the expression "prescription rights". We have heard of other rights but it makes sense that people would have access. That was one of the points made. As part of the meeting this morning, there was a proposal that today, International Women's Day, the Oireachtas Joint Committee on Health would call on the Minister for Health to take immediate steps to make oral contraceptives available without prescription from community pharmacies, as is the case in many other countries. The committee makes this call to bring Ireland into line with WHO policy to reduce costs and increase access, especially for new communities, younger cohorts, and ethnic minorities. The proposers were Deputies Róisín Shortall and Neasa Hourigan.
Róisín Shortall (Dublin North West, Social Democrats)
Link to this: Individually | In context | Oireachtas source
It stands on its merits. It just does not make sense that a barrier to accessing oral contraception exists. It is appropriate that we do this today and I thank the group for their explanation for the thinking behind it. It is about bringing us into line with other countries.
Martin Conway (Fine Gael)
Link to this: Individually | In context | Oireachtas source
I commend Deputies Shortall and Hourigan on an excellent motion that makes complete common sense.
Regarding medications, some branded medications are quite expensive but there are alternatives that are far cheaper. If a prescription is written for a specific drug, and if there is a cheaper alternative available, is there any scope for pharmacists to be able to facilitate people getting the cheaper medication?
Dr. Susan O'Dwyer:
There are structures in place at present for medicines to be interchanged. The HSE has an interchangeable list for certain medications. There is a range of medications on the list and pharmacists are obliged under legislation to supply the cheapest unless there are specific instructions on the prescription from the prescriber to, for example, supply the original brand. If we look at the types of medications that are being used, they are becoming more complex. There are many so-called high-tech medications and more and more of them are becoming available. In that interchangeable space, there can be substitution of the original branded product for what we could call a "biosimilar". Pharmacists could probably be facilitated to do more in that space to help with the cost that is only going to get higher in the coming years.
Seán Crowe (Dublin South West, Sinn Fein)
Link to this: Individually | In context | Oireachtas source
Is there any way of speeding up the reimbursement process? Is that slow? Would that be helpful? Like everyone else, pharmacies are probably facing into difficult times with energy costs. We have already heard about increased transport costs from people who are supplying the medicines. At the end of the day, that is going to have an impact on the customer. Is there anything that the system could do to speed things up? It is about money in people's pocket in relation to these things. Can the system respond a lot quicker to pharmacists' demands?
Mr. Dermot Twomey:
I thank the Cathaoirleach for that question. It is in the legislation that the Minister has to review the fees paid to pharmacists by the end of June this year.
We have written to the Minister seeking a meeting with him and his colleagues to start that process. We have not seen how it will be set out yet. We are talking about expanding our role and providing additional services, which we can only do if the sector is well reimbursed. Going back, as my colleague Ms Maher said, to 2008, we were paid a higher fee per item than we currently receive. In terms of equity, it is important that our fee is linked to the consumer price index and similar linkages and takes into account inflation, going forward.
Seán Crowe (Dublin South West, Sinn Fein)
Link to this: Individually | In context | Oireachtas source
There was no mention of it this morning but I am conscious that pharmacies helped to roll out the Stop Smoking campaign. Are there similar campaigns the IPU feels would be worthwhile to come under the umbrella of Irish pharmacies?
Dr. Susan O'Dwyer:
There are pharmacies that have delivered services in that area. If we think about what pharmacies can do, preventative healthcare is a huge area in keeping people well and healthy. Pharmacists are very involved in primary prevention, as well as secondary and tertiary prevention. The piece before diagnosis and stopping the patient from developing a condition is important. Pharmacy is ideally placed to intervene in that area. Some pharmacies deliver services in that space but not many are funded. Again, it is about equity of access, population level and the ability to make use of the infrastructure already in place to support the health and well-being of the country.
Seán Crowe (Dublin South West, Sinn Fein)
Link to this: Individually | In context | Oireachtas source
What is the pushback regarding the shingles vaccine? Members have expressed that it seems sensible to roll it out at that level. Where is the blockage in the system? Does the IPU have any insight into that?
Bernard Durkan (Kildare North, Fine Gael)
Link to this: Individually | In context | Oireachtas source
Another particular bone of contention is the issue of new and orphan drugs. They are being checked and passed for use in the EU and a second check is done here, which delays availability to patients. Does the Irish Pharmacy Union have a particular position on this? Cystic fibrosis patients and a number of other patients suffering from various illnesses see the availability of a drug which is readily available in other jurisdictions being held up here because of a debate or dispute between the Department or the HSE and the suppliers, based on cost. Does the IPU have a position that could unlock the problems that have beset us for the last several years? I do not wish to discuss the individual people at this stage.
Seán Crowe (Dublin South West, Sinn Fein)
Link to this: Individually | In context | Oireachtas source
Please do not.
Bernard Durkan (Kildare North, Fine Gael)
Link to this: Individually | In context | Oireachtas source
It is an issue that needs to be moved on.
Dr. Susan O'Dwyer:
We support access to medications for patients who need them but recognise that the State has responsibility for managing the resources it has. It has a limited number of resources, which it must use wisely. It is more of a question for the HSE about its structures and how it manages those processes.
Róisín Shortall (Dublin North West, Social Democrats)
Link to this: Individually | In context | Oireachtas source
I think Deputy Kenny raised a question about a consultant in a hospital giving a prescription on discharge and the patient then having to go the GP. That is not standard in other countries. What is the best way around that?
Róisín Shortall (Dublin North West, Social Democrats)
Link to this: Individually | In context | Oireachtas source
Is it just a matter of allowing a consultant to do that, as well as a GP?
Dr. Susan O'Dwyer:
Structures probably need to be put in place but it would require examining reimbursement and where in the reimbursement process it says that person can prescribe under this community drug scheme and we will accept that as an approval and the pharmacy can dispense on foot of that prescription.
Róisín Shortall (Dublin North West, Social Democrats)
Link to this: Individually | In context | Oireachtas source
It is an administrative change.
Ms Kathy Maher:
No. We do not. As a medicines expert, we spend our time with our patients and if there has to be a brand change, we explain why that is. Generics have to be similar or almost identical to the branded product in terms of medicines, taking the high-tech out of it. With the exception of certain medicines such as anti-epileptics and digoxin, we never interchange certain medicines. For the most part, we always explain to patients when there is a change and we reassure them that it may just be the excipient that is different, such as the lactose or whatever is used to compound the medicine. It is nearly always the same.
Róisín Shortall (Dublin North West, Social Democrats)
Link to this: Individually | In context | Oireachtas source
Regarding the national strategy and an action plan, where are we at the moment? Is it purely aspirational? Are things in train?
Ms Sharon Foley:
There is the will, but the way has not been identified at this point. A commitment is needed to develop that strategy, and, as is usual, a timeframe and a process are also needed to deliver that strategy. That would make it very real. I just came from another sector. The Deputy was involved in the national policy on palliative care. That was done in a very expert way and delivered within a year. It can be done.
Róisín Shortall (Dublin North West, Social Democrats)
Link to this: Individually | In context | Oireachtas source
That case still has to be made and accepted.
Róisín Shortall (Dublin North West, Social Democrats)
Link to this: Individually | In context | Oireachtas source
We are at an early stage.
Ms Sharon Foley:
There is certainly a will among those working in the area, certainly from the IPU and all its members. All the stakeholders we work with seem to be very committed. Medical colleagues also seem to have no issue with the need for a pharmaceutical strategy for Ireland. That will is not enough to convert it into a way at a Department of Health level.
Róisín Shortall (Dublin North West, Social Democrats)
Link to this: Individually | In context | Oireachtas source
That is something we can pursue as a committee.
Seán Crowe (Dublin South West, Sinn Fein)
Link to this: Individually | In context | Oireachtas source
I appreciate the IPU witnesses appearing before the committee this morning. This was a very useful meeting. There are a number of actions the committee will follow through on, particularly in relation to oral contraceptives, on which we passed a motion. We will also provide an update on the minor illness schemes and try to find out about those. We will also try to find out from the Minister responsible regarding pharmacy student places, which was one of the issues raised. We will try to get an update on possible prescribing rights. When the Minister next attends, we will try to get some answers on that. We will attempt to get written replies in the meantime.
Regarding the call for a chief pharmaceutical officer, it would be helpful if the IPU had an expanded paper on that and what role that individual would have and so on. It would assist the committee in its deliberations. The witnesses mentioned other jurisdictions where this individual has been a driver for change. It is important that we examine that. The stock answer we get from the Minister or Department is that there are professional staff from a pharmaceutical background in the system and there may not necessarily be a need for that role. The Minister indicated again that the matter is being kept under review. If the IPU gives the committee more information on it, we may be able to take action on it.
Mr. Dermot Twomey:
I thank the Chair and committee for allowing us to present today. The Chair captured a number of the points very well. Our colleagues would be very pleased if the committee was able to follow up on those action points. It is important to us to examine the cognitive administrative burden, as my colleague, Dr. O'Dwyer, mentioned regarding ICT and e-prescribing. It is becoming more of an issue. Deputy Shortall mentioned Cariban, as did other members. The increasing number of restrictive medicines coming with certain criteria attached is adding to our cognitive and administrative burden.
We are filling paper, for the want of a better word, to see if these products are allowed. We need to use the other side of our brains dealing with the clinical stuff on which I engaged with Deputy Shortall and others previously. That is where we really want to be spending our time. The use of e-health, e-prescribing and something similar to the national medicinal products catalogue is a way to move that forward, make the job easier and, ultimately, achieve better health outcomes for the patient. On another area for follow-up, it is very important to the Irish Pharmacy Union that the process for registering members of the workforce from outside this jurisdiction, in other words, registration of third-country applicants from outside the EU, is speeded up. There is a process there but it is painfully slow. It is taking years. There will be real pressure on the pharmacy sector this summer so it is very important that this issue is looked at.
The final point, as was mentioned, is the need for positive engagement on fees with the Minister and Department in order to underpin the sector, both from a workforce and resource point of view going forward.
Seán Crowe (Dublin South West, Sinn Fein)
Link to this: Individually | In context | Oireachtas source
We thank the Irish Pharmacy Union members for the positive role they played, particularly during the Covid-19 epidemic. I also commend them on the fact that the Irish population are very supportive of the role of pharmacists. They are seen as the first port of call in the case of a minor illness and even in the cases of more difficult illnesses. People go to their pharmacists because they trust them and their doors are open and they are accessible six, if not seven, days per week. Well done on that. I hope some action will come from this meeting, which is what the Irish Pharmacy Union also wants to hear. I thank its representatives for assisting the committee on this very important matter.