Submission by the Irish Pharmacy Union to the
Joint Committee on Health and Children on
Primary Medical Care in the Community
31 October 2008
Submission by the IPU on Primary Medical Care in the Community
1. Introduction
The Irish Pharmacy Union (IPU) is the representative and professional body for community
pharmacists. Its mission is to promote the professional and economic interests of its members.
Members of the IPU aim to provide the best possible professional pharmacy service to all members
of the public. They are committed to delivering a quality, accessible, personal and professional
service that puts the patient first and has as its primary goal the optimisation of the health and wellbeing of society. Pharmacists are accountable for their professional conduct and strive to maintain
the confidence and respect of their patients, customers, the State and other professionals in the
healthcare field.
The IPU welcomes the opportunity to make a submission to the Joint Committee on Health and
Children on Primary Medical Care in the Community and show how community pharmacies can
deliver on Government healthcare priorities and achieve true value for money.
2. Role of the Pharmacist
An estimated 636,000 people visit the 1,540 community pharmacies in Ireland each week. This
makes pharmacies the most accessible and visited part of the health service. Pharmacists are in a
unique position to provide an enhanced primary medical care service to people in the community.
Drawing on existing resources always makes sense. Currently, pharmacists play a vital role in
healthcare delivery but are still one of the most under-utilised resources in the health service. They
are highly qualified healthcare practitioners who are easily accessible to the public in city and town
centres, residential and rural areas throughout Ireland. People need no appointment and they have
ready access in a familiar, informal environment to expert knowledge about medicines in particular
and healthcare generally. With an expertise in medicines, community pharmacists are close to their
patients, know their personal and family history, their social environment and their overall
medications. Easily accessible and always available, community pharmacists meet both the patient
and their carers. They are also greatly trusted by the general public.
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The primary role of the pharmacist is to improve health outcomes by safely dispensing medicines
and advising patients on how to get the optimum benefit from them. Pharmacists are able to
counsel patients on the correct use of their medication and can intervene when a patient requests
advice or visits the pharmacy for any reason. However, there is considerable scope to develop the
current level of professional services delivered by community pharmacies into a more
comprehensive, structured and organised service to the community.
3. Government Healthcare Policy
Governments throughout the western world are developing the role of the pharmacist in primary
care in response to changing demographics, health policies and life expectancy. In many European
Member States, the health authorities recognise that many services, which up to now were not
provided at all or were only provided by other healthcare professionals including GPs and
hospitals, can be provided in a more timely and cost effective manner through community
pharmacies. The authorities in these countries realise that community pharmacy is an untapped
professional resource which, if used to its full potential, can relieve pressure in GP surgeries and
Accident & Emergency facilities in a cost effective manner as well as saving patients time and
money.
The Tallinn Charter, which was signed in June 2008 by all Ministers for Health and Finance under
the umbrella of the World Health Organisation’s Regional Office in Europe, highlights that health
systems should integrate targeted disease-specific programmes into existing structures and services
in order to achieve better and sustainable outcomes. It goes on to say that health systems need to
ensure a holistic approach to services, involving health promotion, disease prevention and
integrated disease management programmes, as well as coordination among a variety of providers,
institutions and settings, irrespective of whether these are in the public or private sector, and
including primary care, acute and extended care facilities and people’s homes, among others. The
Charter also highlights that effective primary care is essential, providing a platform for the interface
of health services with communities and families and for inter-professional cooperation and health
promotion. In the Charter, the Member States commit to promoting shared values of solidarity,
equity and participation through health policies, resource allocation and other actions, ensuring due
attention is paid to the needs of the poor and other vulnerable groups.
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In Ireland, there are a number of Government policies that advocate that healthcare services should
be delivered through primary care where possible.
The Department of Health & Children’s Policy Framework for the Management of Chronic
Diseases entitled Tackling Chronic Disease, published in April 2008, points to the need for an
integrated approach to tackle both the prevention and management of chronic diseases. The
framework sets out the principles which should be applied for effective and efficient management
of chronic conditions. Broadly, the aims of the policy are:

To promote and to improve the health of the population and reduce the risk factors that
contribute to the development of chronic disease (disease prevention programmes); and

To promote structured and integrated care in the appropriate setting that improves outcomes
and quality of life for patients with chronic conditions (disease management programmes).
In the Minister for Health’s foreword, she says that “Much of this care [of chronic diseases] can
and should take place within the primary care setting.” The report goes on to recommend that
future primary care contracts should include enabling provisions with respect to the management of
chronic conditions.
The Joint Committee on Health and Children published a report in April 2007 on the Adverse Side
Effects of Pharmaceuticals. One of the recommendations in this report was that the role of the
pharmacist in community health should be expanded and provision made for regular medication
reviews for all patients. Another recommendation was that there is a need for public information
campaigns to improve public attitudes to the proper use of medicines including:

advising patients that many medical problems are self-limiting and they should not always
demand or expect prescriptions when they visit doctors;

encouraging compliance with courses when a prescription is given;

disposing safely of unused pharmaceuticals in collaboration with pharmacists;

raising awareness of the dangers of self-prescribed medicines including internet, counterfeit
and imported medicines; and

promoting awareness of adverse drug reactions among patients and of the desirability and
the means of reporting them to the Irish Medicines Board.
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In her budget speech on 14 October 2008, the Minister for Health and Children said “We must
promote wellness and disease prevention to allow people to live healthily and independently. We
must ensure that if people need a service, it is provided in their own homes and communities
through primary care.”
The Consumer Strategy Group Report from the Department of Enterprise, Trade and Employment,
published in 2006, called for pharmacists to be given the power to substitute generically.
Over the coming months, the Health Service Executive (HSE), as part of a review of the existing
contract between pharmacists and the State, will be considering with the Union the nature of the
role that could be played by pharmacists in the delivery of healthcare services. The IPU hopes to
take this opportunity to expand the professional role of pharmacists to develop additional pharmacy
services for patients in the community. The objective behind many of these initiatives is to assist
Government in delivery of its health policies by enhancing healthcare services that patients receive
in the community so that patients are less likely to end up in hospital or in nursing home care. The
HSE is looking to make considerable savings whilst ensuring that patients’ needs are
accommodated. Extending pharmacy services can deliver on both these fronts, allowing the HSE to
deliver its core activities in a more efficient and effective way.
4. Extended Pharmacy Services
Patients need better services and health outcomes and Government continues to seek better value
for money. In this context, the Union has been advocating the introduction of the following costsaving initiatives:
a. Medicines Use Review
b. Minor Ailments Scheme
c. Structured Health Promotion Services
d. Health Screening Services
e. Generic Substitution
a. Medicines Use Review
The objective of any review of expenditure on medicines must be done with a view to ensure better
health outcomes for patients and to maximise value for money. A strategic approach should be
adopted therefore which addresses the wider issues of usage, compliance and support for patients.
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In Ireland, once a medicine is dispensed, there is no structured follow-up on drug compliance or
wastage. In this context, the Union is proposing that a one-on-one medicines use review should be
undertaken by a pharmacist with a patient who is on a complicated medication regime. A
pharmacist will review a patient’s medication to identify any problems that might have arisen. Most
likely these would be elderly patients or those who suffer from chronic conditions who would be on
many medications. The purpose of this intervention would be to improve compliance, reduce
leakage to secondary care and reduce wastage of medicines.
One in five older people are concerned that they are not taking their medicines correctly according
to research carried out by the market research company, Behaviours and Attitudes, on behalf of the
IPU in August 2006. Non-adherence to medication is a significant problem for patients with a
chronic condition, with 30-50% of patients not taking their medication as prescribed. D.U.M.P.
(Dispose of Unused Medicines) campaigns have resulted in tons of unused and in-date medicines
being returned by members of the public to pharmacies.
It is clear that there is a huge problem with compliance and wastage in the system. There is a
considerable body of international evidence to suggest that pharmacist interventions, through
medicines management initiatives, lead to better outcomes for patients and quantifiable savings.
In Australia, for example, the Government provided funding for pharmacists to provide domiciliary
medication reviews which resulted in a net saving of AS$100 per review for each patient. In the
USA, it is estimated that non-adherence, including wasted or unused medicines, additional medical
consultations and hospital admissions, costs over US$100 billion.
b. Minor Ailments 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. The basis of the
GMS Scheme is to provide full pharmaceutical services for persons who are unable, without undue
hardship, to provide such services for themselves and their dependants. This raises an issue of
parity of access to such medicines.
Many of the GMS products are available to those who can afford them over the counter without
having to visit a GP to obtain a prescription. However, in order to receive these medicines free of
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charge, medical card patients must visit their GP to get a prescription for these non-prescription
items. The IPU has proposed that GMS eligible patients should not have to go to their GP to
receive treatment for specified minor ailments that can be treated by the pharmacists from the
agreed list of GMS reimbursable items which are exempt from prescription supply.
Public opinion research carried out on behalf of the IPU indicates overwhelming public support for
such a scheme. When asked “Would you be in favour of pharmacists being allowed to prescribe
medication on a Minor Ailments Scheme?” 86% of respondents agreed.
Results from an independent study carried out by Drury Research in Ireland (November 2004)
indicated that over two-thirds (67%) of Irish adults said that their pharmacist, not their GP, is the
first port of call for non-serious medical ailments such as coughs, colds and flu. The Drury
Research study also revealed that of the one thousand adults interviewed, over half (53%) felt that
their pharmacist gives them effective, practical advice on non-serious medical ailments.
This enhanced role for pharmacists has been introduced in Scotland and Northern Ireland with
considerable success. It is estimated that in Northern Ireland up to 39% of GP workload in the
winter can be spent dealing with minor self-limiting ailments which could be treated by the
community pharmacist. The IPU believes that pharmacists are in an ideal position to treat routine
ailments. Such a scheme would facilitate more prompt treatment of ailments thereby improving
the quality of life for patients, alleviating pressures on GP surgeries, facilitating patients during
out-of-surgery-hours and also preventing unnecessary use of Accident and Emergency and out-ofhours GP services.
c. Structured Health Promotion Services
With 636,000 people visiting community pharmacies every week in Ireland, pharmacists are in an
ideal position to communicate health promotion messages. The pharmacist has an important role to
play in health promotion, both as a source of education to patients and as a means to improving
lifestyle. The Union initiated a number of its campaigns in recent years in conjunction with patient
groups. The Union is seeking a more structured health promotion role for pharmacists with the
support of the HSE.
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In March 2005, the Union ran a campaign called Ask about Your Medicines, designed to encourage
patients to ask their pharmacist for more information about their medicines. A survey was carried
out at the time of this health promotion which showed that almost 50% of Irish people do not read
the information leaflet contained with non-prescription medications before taking them.
Furthermore, only 30% of those who take other medicines at the same time as non-prescription
medicines check the label/box/bottle or with the pharmacist to see if it is appropriate to do so.
In 2006, the Union focused more on the management of chronic diseases in our health promotions,
looking at heart disease, smoking cessation and diabetes. The main aim of the campaigns was to
make people aware of the risk factors associated with these diseases and to encourage them to
adopt a healthier lifestyle with a view to preventing heart disease and diabetes, rather than waiting
for it to occur and then treating it.
In 2007, the Union’s health promotions focused on the safe use of pain relievers and treatment of
minor ailments. In 2008, we looked at inhaler technique in asthma and medicines in the elderly and
will shortly be running a campaign to highlight the problems associated with overuse of antibiotics.
d. Health Screening Services
Pharmacists are well placed to delivery screening services in the pharmacy. Examples would
include blood pressure and cholesterol screening as well as giving people an indication of whether
they are at risk of developing diabetes. Pharmacists could advise at-risk patients on diet, exercise
and other lifestyle issues as well as referring patients to a GP where necessary. Approximately
60% of the disease burden in Europe is accounted for by 7 leading risk factors comprising high
blood pressure, tobacco, cholesterol, overweight, poor diet and physical inactivity.
Public opinion research carried out by Behaviour and Attitudes on behalf of the IPU indicates that
90% of respondents are in favour of pharmacies offering services such as blood pressure
monitoring, cholesterol testing and sexual health testing and promotion. Early detection of such
conditions is vital from the patient’s perspective and its early treatment is more cost effective for
the State.
In the Tackling Chronic Disease Report, it is estimated that 80% of cardiovascular disease and
Type 2 diabetes as well as 40% of cancer could be avoided if major risk factors were eliminated.
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The WHO estimates that 86% of deaths and 77% of disease burden are caused by chronic disease;
they represent the significant majority of GP consultations and hospital admissions. It is estimated
that, in Ireland, three quarters of the healthcare expenditure is allocated to the management of
chronic diseases. In the UK, it is estimated that 5% of in-patients with a long term condition
account for 42% of all acute bed days.
Despite this, the OECD has estimated that only 3% of total healthcare expenditure goes towards
population-wide prevention and public health programmes. It follows that there should be greater
emphasis on prevention and a greater reorientation towards primary care and more health
promoting services to achieve this.
Data from the USA has shown that chronic disease management programmes can achieve a 50%
reduction in unplanned hospital admissions as well as a 50% reduction in bed day rates for these
conditions.
The treatment of Type2 Diabetes, the most common form of diabetes prevalent in Ireland, costs the
health service €580 million each year. This could be significantly reduced through investment by
Government in the prevention of diabetes and diabetes-related complications. Pharmacists have the
necessary skills to play a key role in this area in an informal and accessible environment.
e. Generic Substitution
In Ireland the pharmacist must dispense the medicine that is written on a prescription. As part of
the proposal for expanding the professional role of the pharmacist, the Union is advocating for
pharmacists to be enabled to dispense an alternative medicine, where it is safe to do so. In this way
the pharmacist would be able to offer less expensive generic alternatives. This is called generic
substitution.
Pharmacists have the right to do this in many other countries such as Denmark, Germany, Finland,
Netherlands, Poland, France, Italy, Portugal, Spain and Sweden.
The Pharmaceutical Care Management Association in the USA calculates that for every 1%
increase in generic utilisation, there is a 0.5% drop in overall drug expenditure. In Finland in 2003,
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generic substitution by pharmacists occurred on 14% of all prescriptions leading to savings of €40
million which represents 5% of the total medicines bill.
In Ireland, the range of annual savings from generic substitution at different price levels is
estimated at €9.0 million to €12.7 million on the Medical Card Scheme and €6.4 million to €9.1
million on the Drugs Payment Scheme for the top 30 drugs by expenditure (based on top 30 drugs
prescribed on GMS and DPS in 2003). However, the Union believes that this is a conservative
estimate and that greater savings could be achieved through a pharmacist-led generic substitution
scheme. The Union has made a number of submissions calling for generic substitution but the
Department of Health and Children and the HSE have not as yet taken up this proposal.
f. Other Community Pharmacy Services
There are a number of other extended community pharmacy services which the Union would like to
see introduced into community pharmacies, for example, monitored dosage systems, services to
residential/nursing homes, extended methadone services, pharmacy based needle exchange,
vaccination clinics, community based palliative care services, pharmacy based warfarin clinics and
chronic diseases management services. The Union would be happy to furnish the Committee with
further details of these services if required.
5. Conclusion
Community pharmacists, as the experts in medicines and as independent health professionals, are
recognised as a valuable resource capable of delivering more on Government healthcare priorities
in a timely and cost effective manner which would provide true value for money. With the shortage
of funding for the HSE in the current economic climate, it makes sense to look for new ways to
deliver healthcare services to patients. The forthcoming merger of PCCC and the National
Hospitals Office in September 2009 provides an ideal opportunity for the HSE to move a
significant number of healthcare services out of secondary care and into primary care. Community
pharmacies provide the perfect location for some of these new primary care services to be delivered
to patients.
The Union is available to meet with the Joint Committee on Health and Children to discuss the
issues raised above or indeed any other relevant issues.
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