Department of Health Statement of Strategy 2016-2019 Public Consultation 12 September 2016
Executive Summary Introduction The Irish Pharmacy Union (IPU), with 2,200 members working in almost 1,800 community pharmacies, is the representative and professional body for community pharmacists in Ireland. Members of the IPU welcome the commitment of the Programme for a Partnership Government to prioritise safe, timely care, as close to patients homes as possible. Members of the IPU also welcome the commitment that, within two years, the role of the community pharmacist will be expanded. Community pharmacists will play a key role in delivering on these commitments through working collaboratively with other health professionals, the Department of Health (DoH) and the Health Service Executive (HSE). The development of pharmacy services is essential for the optimisation of healthcare services in Ireland. This submission outlines the priorities the DoH must adopt in planning their strategy with regards to community pharmacists over the period 2016-2019. 1. Primary Care Some 1,800 pharmacies are established throughout the country, located in every town and village in Ireland. They have existing infrastructure in place that can be used to deliver increased services without any additional capital cost. These pharmacies are ideally placed to provide services to patients close to their own homes. The DoH must utilise this existing resource to its optimum. 2. Creating a Healthy Ireland Community pharmacists are ideally placed to provide advice to patients on a range of health matters which, if dealt with in a timely manner, would prevent much illness and optimise management of chronic illness in later life. Community pharmacists can provide advice and recommend treatment on issues such as smoking cessation, weight loss and sexual health. The DoH must set out in its strategy a clear commitment to providing equity of access to these services for all patients. The DoH must fund public health campaigns and recognise the role that community pharmacists can contribute to these campaigns. 3. Expanding the Role of Community Pharmacists There are many services that pharmacists are uniquely qualified to deliver. The role of pharmacists must be enhanced in order to meet the government s target of expanding the role within a two-year period. These expanded roles include treatment of minor ailments, medicine use support and optimisation through New Medicine Service and Medicine Use Reviews, vaccinations and chronic disease management. These services, if made available to 2
the general population, would relieve pressure on other areas of the health service, such as Emergency Departments and GP practices, thus also helping to meet the government s commitments for improved and efficient acute services. The DoH must set out in its strategy a plan to engage with community pharmacists as a matter of priority. 4. Health Service Reform Plans for the implementation of a patient identifier and a universal use of data for both secondary and primary care and subsequent development of an electronic health record (EHR), with appropriate levels of access for health professionals including pharmacists involved in the care and treatment of a patient, must be set out in the Department s strategy. A Disposal of Unused Medication Properly (DUMP) Scheme must be established in the interests of public safety. An urgent plan to tackle medicine shortages is also needed as patients health and wellbeing is being put at risk by the increasing incidence of shortages of critical medicines. 5. Pharmacy Contract The current pharmacy contract was agreed in 1996. The contract predates the Pharmacy Act 2007 by more than a decade and does not accurately reflect the legal or regulatory framework that pharmacies operate in today. The DoH must immediately prioritise the commencement of negotiations with the IPU on the formation of a new contract in order to achieve the government s aim of expanding the role of community pharmacists within two years. 3
1. Primary Care The DoH Primary Healthcare Strategy envisages that pharmacy services should be dispersed throughout the community as part of a network of healthcare providers with appropriate linkages to the primary care team. The funding of 80 additional primary care centres is welcome. The DoH, in its strategy, must also acknowledge that there is existing infrastructure, namely pharmacies, in place that can deliver services to the population with no additional capital cost. Pharmacies are embedded within every community and their accessibility means they are ideally placed to meet population health needs. The transfer of services to primary care should allow for the provision of a wider range of services, through pharmacies, at a lower cost per intervention. Acute hospital services have been under pressure for many years, with people on long-term waiting lists and overcrowding in Emergency Departments seemingly perennial intractable problems. By devising a joint approach to both acute and primary care planning, many pressures on the acute services could be relieved. The failure to fully implement the Primary Healthcare Strategy announced in 2001 must not be repeated. Primary care is where the vast majority of healthcare needs can be addressed, at the most appropriate level of complexity and least cost. The DoH must move immediately to ensure that when primary care services are being developed that they work with the IPU and its members to optimise the services that community pharmacists can deliver for patients in their own locality. 2. Creating a Healthy Ireland Community pharmacists improve the health and wellbeing of the population by promoting health and supporting and enabling people to adopt healthier lifestyles. With Irish people making 85 million unique visits to community pharmacists each year, pharmacists are in an ideal position to communicate health promotion messages. 2.1 Smoking Cessation Community pharmacists are in a unique position to offer advice and initiate treatment to assist people to quit smoking. Most people are receptive to advice. In order to make Ireland tobacco free by 2025, the DoH must continue to invest in health promotion throughout all sectors of society, including pharmacies. The introduction in 2014 of a smoking cessation service by Irish pharmacies was most welcome and is making a significant contribution towards achieving the government s aim. In the interests of equity and population health, access to this service, currently offered only on a private basis, should be expanded to GMS patients. 4
2.2 Obesity Implementing a physical activity plan through all sections of society is a key requirement in tackling obesity. This year, as part of RTÉ s Operation Transformation campaign, Million Pound Challenge, almost 1,000 pharmacies signed up to carry out weekly weigh-ins and provide weight management advice to patients. Pharmacists have an integral role to play in the campaign as frontline healthcare professionals in communities across the country. Last year s one-day collaboration with pharmacists, Know your Numbers, was described by Operation Transformation as one of the most important days in Operation Transformation history. Community pharmacists have delivered a number of such campaigns in recent years in conjunction with patient groups and the HSE. The IPU are seeking a more structured, long-term, health promotion role, in relation to obesity with the support of the DoH. 2.3 Sexual Health Strategy Risky sexual behaviour is common in Ireland, with surveys indicating that 17% of those having sex outside of a steady relationship do not use any contraception. The Programme for Government commits to implementing a sexual health strategy. Community pharmacists can play a key role in this strategy. Health promotion campaigns related to sexual health in the UK involving community pharmacists have proved very effective. The public should be advised to ask their pharmacist about sexual health through health promotion messaging. Pharmacists deliver cost-effective advice, are near to the patient s home, are easily accessible and are open 50% longer than GP clinics (a key factor in accessing emergency contraception). An amendment to legislation is planned to allow medical card holders avail of pharmacybased Emergency Contraception services, which are already available to private patients. The DoH must act immediately, once the necessary legislation is in place, to enable equity of access for all women. 2.4 Health Check Service Early detection of chronic illnesses, coupled with early intervention and treatment, was a cornerstone of the previous Government s Healthy Ireland strategy. Pharmacy-based health checks would have significant advantages in terms of reach, accessibility and costeffectiveness. Health checks could prove effective in identifying those at risk of developing a chronic disease such as diabetes mellitus, cardiovascular disease, osteoporosis and chronic obstructive pulmonary disease. 5
3. Expanding the Role of Community Pharmacists The IPU welcomes the commitment in the Programme for Government to expand the role of the community pharmacist within two years. The following expanded roles must be set out in the DoH strategy in order to comply with the Programme for Government. 3.1 Minor Ailment Scheme The primary aim of a Minor Ailment Scheme is to enable medical card patients to receive treatment of common illnesses free of charge, direct from their local community pharmacy, in a timely manner, without the need for a GP visit. Some of the minor ailments which can be treated by pharmacists, in no particular order, include, back pain, indigestion, dermatitis, nasal congestion, constipation, migraine, acne, cough, sprains and strains, headache, dry eye, dry skin, scabies, threadworms and vaginal thrush. A three-month pilot Minor Ailment Scheme involving 19 pharmacies, located in four towns around the country, is due to finish at the end of September 2016. The scope of the pilot is limited to just five ailments. The DoH must strategize for an immediate roll-out of a national Minor Ailment Scheme. Each ailment will have a written protocol, outlining the symptoms of the minor ailment, suggesting appropriate treatments and counselling and recommending where appropriate referral is required. 3.2 Medicine Use Review Service The Joint Committee on Health and Children s Report on the Adverse Side Effects of Pharmaceuticals recommended that the role of the pharmacist in community health should be expanded and provision made for regular medication reviews for all patients. The service would ensure that the patient is prescribed the right medicine for their condition, at the right dose, is taking them correctly and that medication-related issues are identified. The DoH must implement a medicine use review service, which will improve health outcomes and enhance people s quality of life, as well as reducing the need for costly hospital care. 3.3 New Medicine Service This service is designed to assist patients with long-term illnesses to manage their condition and to improve their medication adherence through providing clinical support from pharmacists at the outset of taking new medication. Non-adherence to medication regimens can result in patients conditions deteriorating, requiring admission to acute services. A new medicines service will: Improve patient adherence, which will generally lead to better health outcomes; Increase patient engagement with their condition and medicines, supporting 6
patients in making decisions about their treatment and self-management; Reduce medicine wastage; Reduce hospital admissions due to adverse events from medicines; and Lead to increased reporting of adverse reactions to medicines by pharmacists and patients, thereby supporting improved pharmacovigilance. 3.4 Vaccination Services Legislation introduced in 2011 to facilitate pharmacists participating in the seasonal influenza vaccination programme has been enormously successful. Figures for 2014/2015 season saw 51,560 vaccinations carried out in pharmacies. Making the flu vaccine available through pharmacies has significantly improved access for patients, particularly those in the at-risk category. This undoubtedly has a huge population benefit, again reducing potential admissions to acute services. The DoH must immediately make vaccination for shingles and pneumococcal disease available to medical card patients through pharmacy. A further strategy for the role out of comprehensive vaccination services should be planned in consultation with the IPU. In addition to those vaccines already mentioned, pharmacists could vaccinate for tetanus, hepatitis A and B, as well as travel vaccines. 3.5 Monitored Dosage System Monitored Dosage Systems (MDS) are devices or packaging systems in which doses of one or more solid oral medications can be organised according to day and time of administration, making it easier for patients to comply properly with complicated medicine regimes and also enabling carers to monitor patients use of medicines. This service needs to be utilised by the HSE for the purpose of ensuring the elderly and those with chronic illness can comply with essential treatments. The DoH must formally recognise MDS as a cost-effective, essential service to medical card patients. Reimbursement to pharmacies for this service would be cost-effective, allowing people to remain in their homes for longer and preventing admissions to residential care facilities or acute services. 3.6 Chronic Disease Management The clinical benefits of pharmacist involvement in chronic disease management are compelling; with a large evidence base detailing that pharmacists have the most frequent contact with patients with chronic diseases, due to their accessibility. Pharmacists should be engaged in monitoring of patients conditions and empowered to adjust or extend treatment based on standardised relevant indicators such as hypertension control, lipid levels, blood glucose control etc., as is the case in Canada, and authorised to prescribe appropriate medications in emergency situations when it isn t possible to get a doctor s prescription. This service has the capability of providing access to healthcare services for 7
those in rural (or disadvantaged urban communities) Ireland without adequate access to local GP services. The DoH must develop these services in areas where they have difficulty recruiting GPs in the first instance and then roll out nationally. 3.7 Anticoagulation Service Community pharmacists, as experts in medicine, have an ideal skillset to manage patients on warfarin successfully. Examples exist of pharmacies successfully providing anticoagulation services in Ireland. With appropriate supports from the DoH and the HSE, this service could be rolled out to more pharmacies with the attendant cost savings for the HSE, which currently provides the service in the hospital setting at great cost. The benefits for patients is that they would no longer have to travel to a hospital and to see their Time in Therapeutic Range (a key measure of the quality of warfarin treatment) improved. Again, this service could be expanded into more pharmacies in areas of identified need without the HSE incurring upfront capital or infrastructural costs. 4. Health Service Reform 4.1 ehealth The IPU is engaging with the office of the Chief Information Officer on ehealth and epharmacy, particularly in relation to the development of standards for e-prescribing, electronic transfer of prescriptions and production of a National Product Catalogue. In its strategy, the DoH must set out a plan for the implementation of the Individual Health Identifier. It must also set out a strategy to achieve the government s aim of an IT health infrastructure with universal use of data to improve integrated care and outcomes across primary and secondary care, including the development of an electronic health record (EHR), with appropriate levels of access for all health professionals, including pharmacists, involved in the care and treatment of a patient. 4.2 DUMP Scheme A Disposal of Unused Medication Properly (DUMP) Scheme is a potential way of restricting access to means for suicide and deliberate self-harm, accidental poisoning in children and preventing environmental pollution, as it encourages patients to return their unused medicines to their local community pharmacy. Such schemes have operated from time to time in certain regions in the past but, to be truly effective, need to be established nationwide on a sustainable basis. 4.3 Medicine Shortages Medicine shortages are an ongoing, increasing and very complex problem that is putting patients health at risk. On a daily basis, there are multiple shortages of medicines in the 8
supply chain and, in many cases, a nationwide lack of critical prescription medicines. Patients can sometimes be left waiting for weeks to get a new supply of a common drug. Not only is this putting their health at risk but it is causing undue stress, fear and anxiety for them. Instead of directing their efforts and professional expertise towards the needs of patients, pharmacists and their staff are spending from five to 30 hours per week resolving medicines shortages and firefighting on behalf of their patients. Falling medicine prices have exacerbated the problem, as more medicines are either being exported out of the country to other jurisdictions where medicine prices are higher, or are simply not being supplied. While it is entirely appropriate that the HSE should seek to maximise value for the spend on medicines, it needs also to be aware of the impact of pricing policies on continuity and security of supply. This is an extremely serious situation that needs to be urgently tackled. We propose that a dedicated working group be established made up of representatives from the DoH, the HSE, the Health Products Regulatory Authority and the IPU to identify and monitor medicine shortages and take immediate, appropriate action on a drug-by drug basis when shortages arise. 5. Pharmacy Contract The Programme for Government sets out as one of its objectives the need for a new General Practice contract to address the changing needs of chronic care within the community. Equally, one of the crucial building blocks in developing and reorienting the model of care towards primary and community care is developing a new pharmacy contract fit for the 21 st century. Much of the 1996 pharmacy contract is now out of date and is in urgent need of review. A number of schemes and new services have been introduced in an ad hoc manner and, at times, confusing changes or restrictions in the terms and conditions and rules applicable to the schemes have been made. A new contract is essential in planning for the expansion and extension of community pharmacist roles. It is also essential in introducing clarity to existing arrangements. 9
Conclusion The cornerstone of any single-tiered, universally accessible health service will be the development of primary care services. The movement to primary care, across all health sectors, should allow for the provision of a wider range of services, at a lower cost per intervention. The IPU supports government plans to reduce the mandatory co-payment on the drugs payment scheme and prescription charges for medical card holders and further believes that the DoH must work to remove such financial barriers that impede the population s access to healthcare. There is clear evidence to show that pharmacy-based services in other jurisdictions have led to considerable improvements in patients health outcomes and efficiencies in healthcare budgets. The focus of the DoH must be towards the creation of a patient-focussed health service, delivered at the lowest level of complexity. Pharmacists play a vital role in ensuring patient safety and wellbeing. Public opinion research conducted by Behaviour & Attitudes repeatedly shows that there is a strong appetite among the public for additional healthcare services to be delivered through pharmacies. The IPU, as community pharmacists representative body, is available and willing to engage on a positive change agenda. The DoH, for its part, must be pro-active in developing a strategy for the period 2016-2019 and set out in that strategy a plan for engaging with community pharmacists to deliver on the Programme for Government and, in particular, the expansion of the role of pharmacists for the betterment of the healthcare system and the benefit of patients and the public. The IPU is available to discuss this submission in greater detail, if required. 10