Submission by the Irish Pharmacy Union on Budget 2018

Submission by the Irish Pharmacy Union on Budget 2018 August 2017

Introduction The Irish Pharmacy Union (IPU) is the representative and professional body for community pharmacists. With over 2,200 members working in 1,700 pharmacies, which employ 20,000 people, our mission is to promote the professional and economic interests of our members. Community pharmacists are highly-trained healthcare professionals. In 2016, there where nearly 85 million visits to community pharmacy outlets or 19 visits per annum per man, woman and child in the State. This provides an unprecedented level of access to the general public, providing the pharmacy sector with an opportunity to significantly expand our role to the benefit of both the patient and the State. Pharmacists understand the broader political and economic context in which Ireland operates. Government and HSE cutbacks and ongoing pressure on margins due to reference pricing, combined with an onerous regulatory regime, increased competition, reduced consumer spending and rising utility and staff costs, have all conspired to undermine the traditional business model of pharmacies around the country. Since the introduction of the Financial Emergency Measures in the Public Interest (FEMPI) Act in 2009, community pharmacy has, directly and indirectly, contributed over 2.64 billion of savings to the Exchequer from cuts to pharmacy payments. Summary of Key Proposals In summary, the following are the key proposals from the IPU for Budget 2018: Immediately commence the unwinding of FEMPI measures which were applied to community pharmacy contractors, in recognition of the significant contribution they have made and continue to make towards achieving savings for the State during the recent financial crisis and their ongoing cooperation with reimbursement reform and the delivery of key audit and accountability measures; 2

Reinstate the 4.25% PRSI rate for lower paid workers from the current 8.5% rate. The measure should be reintroduced for a further three-year period to assist in sustaining and increasing employment in the sector; The Earned Income Tax Credit should be increased from 950 to 1,650 and should thereafter be increased in line with the PAYE Tax Credit to ensure equalisation is maintained into the future; The fees for registering both an individual pharmacist and a pharmacy business in Ireland need to be brought into line with those in other European countries, including those across the border; Introduce further measures to rejuvenate city, town and village centres by implementing a number of the key recommendations from the Framework for Town Centre Renewal, produced by the Retail Consultation Forum; A nationwide DUMP (Disposal of Unused Medicines Safely) Scheme should be introduced by the HSE and all local authorities that would promote safety by encouraging the public to return their unused medicines to pharmacies; The Medical Card Prescription Levy should be phased out and, at the very least, especially vulnerable patients should immediately be exempted from paying it; Address the impact of the black market on the pharmacy sector; and The role of the pharmacist should be expanded to include the introduction of pharmacy-based services available in other jurisdictions including a Minor Ailment Scheme, New Medicine Services and an expanded vaccination service, which have been shown to offer cost-effective access to improved healthcare. These proposals are outlined in further detail below. 3

1. FEMPI Unwinding The Financial Emergency Measures in the Public Interest Act 2009 (FEMPI Act) and the regulations made under it were used to cut payment rates to pharmacists and other professionals, which, if it were not for the emergency in the State s finances, would have been unlawful. Since 2009, there has been a minimum of 1.23 billion in cuts to payments to pharmacies under FEMPI. This comprises 456 million in cuts to dispensing fees and mark-ups (see table 1.1 below) and 776 million (table 1.2) in cuts to the wholesale margin/ingredient cost. By any measure, the cuts in the amounts and rates paid to community pharmacy contractors under the 2009, 2011 and 2013 regulations have been exceptionally severe in their effect on community pharmacy contractors but have had a significant impact in achieving savings for the State. Table 1.1: Reductions in Fees and Mark-ups Paid to Pharmacists by the State Year Pharmacy No. of items Mark-up & Reduction State savings fees & mark- dispensed fees per item per item ups under State since 2009 schemes 2016 (estimate) 73,500,000 5.05 0.91 66,885,000 2015 389,740,000 73,542,223 5.30 0.91 66,923,423 2014 381,070,000 72,715,536 5.24 0.97 70,534,069 2013 393,930,000 74,378,504 5.30 0.91 67,684,438 2012 403,860,000 75,724,736 5.33 0.88 66,637,767 2011 386,630,000 72,023,261 5.37 0.84 60,499,539 2010 372,990,000 69,251,377 5.39 0.82 56,786,129 2009 420,960,000 67,825,991 6.21 Total 455,934,014 4

Table 1.2: Reductions in Medicine Reimbursements Paid to Pharmacists by the State Year PCRS payments No. of items Cost Reduction FEMPI State savings for medicines dispensed per per item reductions under State item since 2009 schemes 2016 73,500,000 13.01 5.77 85,500,000 424,095,000 (estimate) 2015 956,750,000 73,542,223 13.01 5.77 85,461,329 424,338,627 2014 979,010,000 72,715,536 13.46 5.32 87,449,695 386,846,652 2013 1,053,290,000 74,378,504 14.16 4.62 94,084,728 343,628,688 2012 1,161,460,000 75,724,736 15.34 3.44 103,746,972 260,493,092 2011 1,114,610,000 72,023,261 15.48 3.30 99,562,113 237,676,761 2010 1,191,880,000 69,251,377 17.21 1.57 106,464,227 108,724,662 2009 1,273,770,000 67,825,991 18.78 113,779,020 Total 776,048,083 2,185,803,482 Since 2009, 2.64 billion has been extracted from the community pharmacy sector, 1.41 billion of which was not under FEMPI. For example, the savings achieved under reference pricing alone amounted to an extraordinary 313 million by the end of July 2016. In 2009, the Irish economy and its financial system were in a very difficult place. That year, gross domestic product (GDP) contracted by 5.6% and gross national product (GNP) contracted by 8% 1. Ireland s international reputation and, consequently, the ability of the Government to borrow at realistic borrowing costs were starting to come under serious pressure. By contrast, 2016 was a year of strong growth for the Irish economy. 1 The figures and analysis in this section have been provided by economist Jim Power. 5

For 2016 as a whole, initial estimates suggest that gross domestic product (GDP) expanded by 5.2%; gross national product (GNP) expanded by 9%; consumer expenditure expanded by 3%; investment expanded by 45.5%; imports of goods and services expanded by 10.3%; and exports of goods and services expanded by 2.4%. The investment outturn is distorted by the shifting of items, such as intellectual property rights into Ireland, but notwithstanding such accounting transactions, the underlying growth picture was solid on all fronts and the recovery was broad based. Having come through a very difficult period, the economy is now recovering strongly, which is having a very positive impact on all fiscal indicators and the international reputation of Ireland. In line with the growth in the economy, there has been an unwinding of FEMPI for public servants. The cost of the restoration of public pay under the FEMPI Act 2015 will be 844 million up to September 2018, which is equivalent to 38% of the 2.2 billion savings made in the public pay bill under FEMPI. It is no longer justifiable, therefore, for there not to be a substantial reversal of the cuts in payments to pharmacists under FEMPI. The IPU notes the commitment in the Programme for a Partnership Government to prioritise safe timely care as close to patients' homes as possible. We also note the commitment that, within two years, the role of the community pharmacist will be expanded. Community pharmacists will continue to 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). In addition to enhancing primary care services from this perspective, the IPU recognises the potential efficiencies and savings which may be achieved through initiatives such as a New Medicine Service for asthma patients, Medicine Use Reviews for patients in nursing home settings and a Minor Ailment Scheme. 6

In addition to the foregoing savings, the IPU has engaged fully with the HSE and the DoH to develop and enhance primary care services, improve the electronic interface between community pharmacy contractors and the HSE and to ensure greater financial accountability and probity for all parties. Recommendations 1. The previous Minister for Health, Leo Varadkar, made a clear commitment to the community pharmacy sector that a reversal of just 2.5 million would be ensured in 2016, which represents a tiny proportion (0.021%) of the total savings of 1.2 billion resulting from FEMPI, directly attributable to rates paid to pharmacists. This is in addition to the other savings effected by the State, which the Minister is required to take into consideration. As a gesture of good faith on behalf of the current Minister, this commitment made by the previous Minister should be honoured and these payments should be immediately reinstated to pharmacy contractors. 2. The process for the complete unwinding of FEMPI should see the implementation of the Independent Body on Pharmacy Contract Pricing, established by the Minister for Health and Children in 2008 and chaired by Sean Dorgan. The report recommended a tiered fee of 7.00 per item dispensed for the first 20,000 items, 6.50 for the next 10,000 items and 6.00 for each other item dispensed per month. 3. The current dispensing fee structure is 5.00 per item dispensed for the first 1,667 items per month, 4.50 for the next 833 items per month and 3.50 for each other item dispensed per month. The IPU is of the view that the current fee structure should be abolished (and as a consequence so should the threshold bands) and a standard fee of 5.00 be applied. It is estimated this would return 60.6 million in additional annual fees to community pharmacists. 4. At the very least, the Minister should increase the monthly threshold to which the 5.00 fee applies from 1,667 to 2,000 items and the second band (to which the 4.50 fee applies) from 833 to 1,000 items as a first step to unwinding FEMPI in 2017 for community pharmacy 7

contractors. It is estimated that such an alteration to the bands would return 11.5 million to community pharmacists. 5. It is the view of the IPU that the Minister should engage with the IPU to agree a process and timetable for the implementation of these measures. 6. The Minister must also immediately provide for full reimbursement of all refrigerated medicines, which are currently systematically under-reimbursed by 4.8% and therefore impose an unfair cost on community pharmacy contractors and calls into question the sustainability of their continued supply on the community drug schemes. 2. Employment Costs The reduction of the 8.5% employers PRSI rate to 4.25%, for those earning less than 356 per week, was announced as part of the 2011 jobs initiative and was in place until the end of 2013. This welcome support for job creation and sustainability was not renewed after that date. Consequently, the ending of this measure had a significant impact on many retail pharmacies, particularly those employing part-time staff. There is anecdotal evidence of pharmacies having to reduce staff hours and, in some cases, let staff go as a result of the measure not being extended. The current level of PRSI/Universal Social Charge on top of existing income tax rates is rendering prohibitive the costs associated with employing additional staff members and is also jeopardising the ongoing viability of the employment of existing levels of staff in many pharmacies. Together with addressing the level of taxes imposed on employees to make employment more attractive at the margins, it is also essential that employers PRSI rates are addressed in order to incentivise pharmacy and other retail owners to sustain and increase employment. A first step would be to reinstate the 4.25% PRSI rate for lower paid workers from the current 8.5% rate, up to the threshold of 376. 8

The measure should be reintroduced for a three-year period to assist in sustaining and increasing employment in the sector. Employers PRSI is a direct tax on labour and should be reduced as a matter of urgency to offset the substantial labour costs involved in hiring staff. 3. PAYE allowance for Self-Employed The disparity in the tax treatment between the self-employed and PAYE workers needs to be addressed, in particular the discrimination against Directors and the self-employed with regard to not being able to avail of the full PAYE tax allowance. The earned income tax credit, which increased to 950 in Budget 2017, needs to be increased to the same level as the employee credit (currently 1,650) immediately and subsequently increased in line with the PAYE tax credit to ensure equalisation is maintained into the future. 4. Regulatory Costs The fees charged to pharmacies for registration with the Pharmaceutical Society of Ireland (PSI) are excessive and are a multiple of costs in similar jurisdictions. The annual registration fee each pharmacy must pay to the PSI is 2,135 ( 3,325 on first registration). In Northern Ireland, the first time registration fee for a pharmacy premises is 113 and then 317 per annum for each year after registration, which is only a fraction of the cost of registration in the Republic of Ireland. In their 2012 report A Review and Audit of Licences Across Key Sectors of the Irish Economy, Forfás, policy advisory board for enterprise, trade, science, technology and innovation, made the following recommendation: Recommendation 18 Licensing authorities and bodies need to examine and seek to reduce licence fees in the sectors where the fees are considered to be most onerous. Fees in this category include the annual registration fees for pharmacies, Court Fees for Special Exemption Orders, Private Security Authority Licence fees and Table and Chairs Licence fee." 9

Despite this, the cost of registration with the PSI remains out of line with international comparisons. It is no longer feasible for Irish pharmacists and pharmacy businesses to pay these fees. It is unsustainable for one arm of the State, the HSE, to continually drive down unit payments to the pharmacy profession (as has happened under the FEMPI Act and the Health [Pricing and Supply of Medical Goods] Act) while, at the same time, another arm of the State, the PSI, continues to enjoy the highest pharmacy registration fees in Europe, if not the world. In order to ensure the sustainability of local pharmacy services, these charges need to be immediately brought into line with those in other European countries, in particular those which apply across the border. 5. Introduce further measures to rejuvenate City, Town and Village centres A Retail and Town Centre Renewal working group, set up by the Retail Consultation Forum, prepared a Framework for Town Centre Renewal 2 which was launched by Minister Mitchell O Connor in April 2017. The Framework will support towns and villages through their local authorities to address the challenges of creating a vibrant and viable town centre, which will support enterprise and economic development across towns and villages throughout Ireland. To address the challenges of town centre renewal of all sizes of villages, towns and cities, the IPU would like to see the recommendations in the Framework document being rolled out across local authorities and central Government with the support of other key stakeholders including pharmacy and other retail representatives. Recommendations include greater coordination across local authorities in their approach to town centre management; identifying further funding streams for town centre renewal; a National Town Centre Health Check Programme; and a central portal for town centre renewal resource material and case studies. 2 Available at: https://www.djei.ie/en/publications/a-framework-for-town-centre-renewal.html 10

Recommendations Develop a National Town Centre Health Check Programme and a central portal for town centre renewal resource material and case studies; Identify further funding streams for town centre renewal; Reduce the rates burden on businesses with an increase in funding for local authorities; Ensure rigorous application of the Sequential Test as outlined in the Retail Planning Guidelines; and Explore options for further incentives to encourage people to live in town centres. The Living Cities scheme needs to be reviewed and amended to facilitate greater take-up and broadened to include towns and villages. 6. Nationwide DUMP (Disposal of Unused Medicines Safely) Scheme Waste charges are an issue for all small businesses. For pharmacies, the costs are higher than for other retail-type businesses due to the specialised collection and disposal services required for the disposal of medicines. There are significant public safety benefits, however, to encouraging people to dispose of their unused or out-of-date medicines at their local pharmacies but this must be done without adding significant costs to the pharmacies receiving the medicines. The issue of self-harm due to overdose is well documented. 4,490 children in Ireland were accidentally poisoned in 2015 according to the Poisons Information Centre in Beaumont Hospital 3. 7,300 cases presented at A&E departments in 2015 due to deliberate drug overdose, according to the National Suicide Research Foundation 4. In most cases, prescription or over-the-counter medication is involved. There are around 50 cases a year of suicide as a result of drug overdose. These figures highlight the threat caused by unused medicines in Ireland many of which are kept in unsecured locations in people s homes. 3 Annual Report 2015, Poisons Information Centre of Ireland 4 Annual Report 2015, National Self-Harm Registry Ireland 11

The introduction of a nationwide DUMP (Disposal of Unused Medicines Safely) Scheme is an important measure to prevent the problems associated with holding on to unused or out-ofdate medicines. We are all well aware of the effects of uncontrolled disposal of medicines into the environment and of the potential for accidental poisoning where there are excess medicines stored in the home. By encouraging patients to return their unused medicines to their local community pharmacy, thus restricting access to unused medicines, the introduction of a DUMP Scheme can reduce the risk of suicide, deliberate self-harm, accidental poisoning in children and help prevent environmental pollution. Most community pharmacists accept unwanted medicines returned by patients to their pharmacies and dispose of them at their own expense. However, this is no longer sustainable as it is becoming an increasingly expensive burden at a time when pharmacies are under unprecedented economic pressure. To ensure continued access to this potentially life-saving service for the public, funding should be put in place for a nationwide DUMP Scheme, allowing the public to return their unused medicines to pharmacies, which would have significant ongoing health and public safety benefits. 7. Prescription Levy The medical card prescription levy, currently 2.50 per item, has increased fivefold since it was first introduced in June 2010 at 0.50 per item. Many patients, particularly those on fixed incomes, just cannot afford to pay the levy. Instead, they gamble with their health every day either by reducing their medication or by stopping it entirely. The ultimate outcome is sicker patients with more complex medical needs needing advanced care in an already extremely overburdened health system. The imposition of the levy is creating more future demand for a health service that is already struggling to cope. 12

The impact of the levy can be seen from the findings of a Behaviour & Attitudes Survey on behalf of the IPU, undertaken in March of 2015 5, in which 28% of medical card holders said that they think twice about taking their prescribed medicines because of the cost of the levy and one in seven confirmed that they have not filled a prescription because of the levy. In addition, a study published in March 2016, which was funded by the Health Research Board and co-authored by researchers in University College Cork (UCC) and Trinity College Dublin, and which only looked at the impact of the increase in the levy from 0.50 to 1.50, found that prescription charges on the medical card scheme led to reductions in the use of medicines by Irish patients, with some types of medicines being affected more than others. While the levy was reduced in the last Budget for those aged 70 and over and their dependants (down to 2.00 with a monthly cap of 20) the IPU would like to see a complete phasing-out of the levy and, at the very least, that it is not applied to especially vulnerable patients, including those in residential care settings, homeless patients, patients receiving treatment under the Methadone Treatment Scheme in respect of other medication that they may require, patients with intellectual disabilities, and palliative care patients. 8. The Impact of the Black Market on the Pharmacy Sector The black economy is having a serious impact on businesses throughout the country in terms of lost revenue and jobs in legitimate companies that are endeavouring to trade through these difficult times. The pharmacy sector is no different and is being affected in two areas in particular: the purchase of counterfeit medicines online and the availability of counterfeit cosmetics. Notwithstanding the high profile seizures by the Gardaí and the Revenue Commissioners, more needs to be done. We would recommend that: There should be more regular checks on casual traders to ensure that counterfeit products are not being sold; and 5 Public Attitudes to Pharmacy Survey 2015, Behaviour and Attitudes 13

There needs to be increased public awareness of the potential consequences to an individual s health from purchasing counterfeit medicines and cosmetic products, as well as highlighting the loss of revenue to the Exchequer, which ultimately affects all consumers as taxpayers. 9. Expanded Role for Pharmacists In an environment of demographic pressures, a growing and ageing population and limited resources, the healthcare system is under unprecedented pressure, with increasing demand for healthcare services resulting in hospitals being overstretched and GPs struggling with their existing workloads, which will, according to themselves, continue to increase with the ongoing expansion of universal healthcare. There is clear evidence to show that pharmacy-based services in other jurisdictions have led to considerable improvements in patients health outcomes and considerable savings to healthcare budgets. In England, Scotland and Canada, for example, where demand for GP services exceeds the available capacity, the unique skills and expertise of pharmacists are being used to enhance access to healthcare. In Canada, the Government mind-set has changed: all professions are now expected to practise to the full extent of their skills to maximise the public benefit of healthcare training and resources. Thus, pharmacists' scope of practice has been extended to include Chronic Disease Management: monitoring patients with chronic illnesses, renewing and adjusting their prescription medicines to ensure tighter control of their symptoms. Despite a severe shortage of primary care doctors, extending pharmacist responsibilities in this way has resulted in better access to healthcare and improved management of illnesses such as heart disease and diabetes. Canadian pharmacists are also authorised to prescribe medications in emergency situations, when it isn't possible to get a doctor's prescription. 14

Data from Scotland shows that in-depth Medicine Use Reviews, conducted by pharmacists with patients suffering from chronic illnesses, reduced hospital readmission rates by a third. The introduction of these services in pharmacies abroad has proven to deliver significant benefits to both patients and the State by taking pressure off other parts of the healthcare system, including GPs and hospitals, allowing them to focus on those more complex patients who require medical intervention. Pharmacists in Ireland have the requisite expertise, skill set and accessibility to introduce services like Health Screening, a Minor Ailment Scheme, New Medicine Service or Chronic Disease Management, all of which would assist in delivering on the Government s programme of improving the health and wellbeing of people living in Ireland. Here in Ireland, the slow process of expanding the role of the pharmacist is already reaping benefits. The introduction of the flu vaccination service and reclassification of emergency hormonal contraception, have already shown that pharmacists can deliver cost-efficient services that patients want and will avail of. From July of this year, females on medical cards are able to avail of Emergency Hormonal Contraception for the first time directly from their local pharmacist without a prescription, but much more can be done. Introducing additional pharmacy-based services would command strong public support. In March this year, a nationwide survey 6 conducted by the Behaviour & Attitudes research company found very strong support for expanding the role of the pharmacist as a healthcare provider; 96% said they would be in favour of the pharmacist being able to prescribe some medicines for minor ailments, while 93% said they would like to see the pharmacy offering services such as blood pressure or cholesterol testing at the pharmacy for a reasonable cost. 6 Public Attitudes to Pharmacy Survey March 2017, Behaviour & Attitudes 15

Nearly two-thirds of respondents (62%) said they sometimes rely on a pharmacist s advice rather than visiting the GP, while 61% said they think twice before going to the GP now due to its expense. With over 1.5 million visits to a pharmacy by the public every week, pharmacists are the most accessed healthcare professional. The time is right to optimise the delivery of primary care by providing appropriate, convenient, accessible and cost-effective healthcare through pharmacies in communities throughout the country. With ever-increasing demand for healthcare as our growing population continues to age, and with the ongoing constraints on the resources available to deliver healthcare, we simply do not have the option of doing nothing. There is an urgent need for a fundamental shift in health policy and the immediate implementation of change. Recommendations The IPU recommends the introduction of the following pharmacy-based services. a. Minor Ailment Scheme The primary aim of a Minor Ailment Scheme is to enable medical card patients to receive treatment for common illnesses free of charge directly from their local community pharmacy in a timely manner and without the need for a visit to the GP. The Minor Ailment Scheme is an internationally-recognised extended pharmacy service, which allows pharmacists to improve public health access, shape future services and broaden pharmacy roles to deliver quality patient care and improve health outcomes. Community pharmacists deal routinely with minor ailments as part of their normal practice, giving advice to patients on how to treat self-limiting conditions and distinguishing between minor illness and major disease. By giving appropriate advice and recommending effective treatments, community pharmacists facilitate more prompt treatment of ailments, thereby improving the quality of life for patients and playing a major role in keeping people with common ailments out of the GP surgery and preventing unnecessary use of A&E services. Furthermore, they act as a filter for referral where a GP consultation is needed. 16

In the UK, the Royal College of General Practice and the College of Emergency Medicine have estimated that one in seven GP consultations and one in 12 A&E attendances could have been dealt with by a visit to a pharmacy. Furthermore, research published in the British Journal of General Practice in July 2013 7 concluded that minor ailments are being dealt with appropriately by Pharmacy Minor Ailment Schemes, that Pharmacy minor ailment consultations are less expensive than consultations with GPs and also that evidence suggests that Pharmacy Minor Ailment Schemes provide a suitable alternative to general practice consultations. In November 2016, the IPU, together with the HSE, completed a three-month pilot Minor Ailment Scheme in four towns around the country. In the evaluation of the pilot, patients reported confidence in the pharmacist s ability to deliver the scheme and identified a high value in having a minor ailment service. They also indicated satisfaction with the level of privacy within the pharmacy setting. The advantages of the scheme include self-care, quick treatment initiation and easy access to help and advice. We now wish to ensure that the scheme becomes a national service and therefore propose that funding be identified to allow the Department of Health and HSE to immediately roll out a national Pharmacy Minor Ailment Scheme. b. New Medicine Service A New Medicine Service aims to provide support for people who have been newly prescribed a medicine for certain long-term conditions or therapies (such as asthma, COPD, Type 2 diabetes, hypertension, antiplatelet/anticoagulant therapy, statin therapy and chronic pain). It consists of a structured intervention at initiation of therapy with follow-up in the short term to improve medicines adherence and increase effective medicine taking. Analysis of the New Medicine Service that has been in place in England since 2011 showed that adherence to treatment increased by 10% and that for each patient taking part in the 7 Br J Gen Pract. 2013 Jul; 63(612): e472 e481 http://www.ncbi.nlm.nih.gov/pmc/articles/pmc3693804/?report=classic 17

New Medicine Service, the NHS saves 190 and the person gains 0.06 Quality Adjusted Life Years. A new study published in August 2017 by The Universities of Manchester, Nottingham and University College London reports that the New Medicine Service in England has created short term savings of over 75 million in the first five years of the service and will lead to savings of over half a billion - 517.6 million - in the longer term 8. In January this year, the IPU commenced a pilot New Medicine Service in 96 pharmacies across 23 counties. Our objective was to explore the operation of the New Medicine Service, in particular the complexity and nature of the consultations that underpin it in terms of patient engagement, age range, advice-giving and support and to determine acceptability to stakeholders, along with reasons for success or lack of success and its feasibility within the service delivery environment. Given the substantial health and economic benefits which have been seen since its implementation elsewhere, a properly-funded New Medicine Service should now be rolled out nationally in Ireland. c. Extended Vaccination Service Making the flu vaccine available in pharmacies has significantly improved access and promoted uptake of this vital public health intervention. We are pleased that the previous Minister for Health legislated for pharmacists to provide vaccination for shingles and pneumococcal disease also, in order to enhance access to these vaccines and thereby improve uptake. However, unlike flu vaccination, the provision of pneumococcal vaccination in pharmacies is not funded by the HSE although it is in general practice. Reimbursement arrangements need to be put in place immediately for pharmacies to provide this vaccine, as is the case for flu vaccination, to encourage its uptake by those patients who would benefit most. 8 Elliott et al PharmacoEconomics 2017 Aug 3. DOI: 10.1007/s40273-017-0554-9 https://www.ncbi.nlm.nih.gov/pubmed/28776320 18

Pharmacists in other countries routinely offer a wider vaccination service. In most states of the USA, in addition to influenza, pharmacists can offer vaccination of meningococcal disease, tetanus and hepatitis A and B, as well as travel vaccines. We would like to see our pharmacy vaccination services extended similarly to include a similarly wide range of vaccines. d. Chronic Disease Management Service The clinical benefits of pharmacy 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 and that pharmacists could provide clinical and cost benefits through the existing community pharmacy network. It is envisaged that chronic disease management will be a collaborative initiative between the GP, practice nurse, community pharmacist and other healthcare providers. e. Reclassification of Medicines The IPU would like to see a greater role for pharmacists in supporting self-care and for an increase in the number of medicines available without prescription, in line with other countries such as the UK and New Zealand. This will enable people to access treatments for minor and self-limiting ailments allowing GPs to focus on more complicated illnesses. Pharmacists would utilise their clinical knowledge to help patients choose the appropriate medication to deal with minor ailments. Medicines that could be reclassified include newer anti-allergy medicines like fexofenadine and a wider range of analgesics, many of which are already available without prescription in the UK and elsewhere. 19

Conclusion It is imperative that the Government reviews and addresses the State-imposed and Statecontrolled costs on small businesses, including pharmacies, in order to maximise sustainable employment and to ensure the continuing provision of high-quality pharmacy services in local communities. It is also essential that no further costs are imposed on pharmacies, which could have a detrimental impact on the survival of the pharmacy or threaten existing employment levels. There must be immediate action to commence the unwinding of FEMPI measures as they applied to community pharmacy contractors, in recognition of the contribution they have made to achieving significant savings for the State during the recent financial crisis. Lastly, the IPU believes that developing the role of the pharmacist will deliver better patient outcomes, as well as generating efficiencies and savings. The challenge now is to ensure that community pharmacy is enabled to deliver more into the future and this requires a new and more strategic approach to be agreed for the delivery of community-based healthcare in the context of overall healthcare reform. This year s Budget can go some way to achieving this. The IPU is available to discuss this submission in greater detail, if required. 20