As the IPU campaign to restore pharmacy fees was proceeding over the last month, issues pertaining to the pay freeze imposed on pharmacists and allowing pharmacists to practice to their full scope were continuously raised in the Houses of the Oireachtas. In this article, Brian Harrison, Director at MKC Consulting, provides an overview of the issues raised, and the responses given by Government, to these and other issues pertaining to pharmacy.
As the deadline for Minister for Health Stephen Donnelly TD (Wicklow, Fianna Fáil) to review pharmacy fees edged closer, the Minister for Health has faced an increasing number of questions from Oireachtas Members about what actions he will take and when.
Many TDs challenged the Minister on when and how he planned to engage with the Irish Pharmacy Union (IPU) on pharmacy fees, including; Steven Matthews TD (Wicklow, Green Party), Peter Burke TD (Longford-Westmeath, Fine Gael), Gerald Nash TD (Louth, Labour Party), Marc Ó Cathasaigh TD (Waterford, Green Party), Paul Murphy TD (Dublin South-West, People Before Profit), Jennifer Murnane O’Connor TD (Carlow-Kilkenny, Fianna Fail), Marian Harkin TD (Sligo-Leitrim, Independent), Colm Burke TD (Cork North-Central, Fine Gael), Paul Kehoe TD (Wexford, Fine Gael), and Róisín Shortall TD (Dublin North West, Social Democrats).
Responding to questions posed by these TDs, Minister Donnelly said that he recognised “the significant role community pharmacists play in the delivery of patient care” and acknowledged the potential for this to be expanded. He said that his Department is currently carrying out a review, and committed to communicating with the Irish Pharmacy Union very shortly.
Michael Healy-Rae TD (Kerry, Independent) asked the Minister if “pharmacy fees will be restored”. Richard Bruton TD (Dublin Bay North, Fine Gael) similarly raised the issue to Minister Donnelly in a statement, noting that pharmacists “feel very aggrieved about financial emergency measures in the public interest, FEMPI, obligations”.
Responding to Deputy Healy-Rae, Minister Donnelly claimed that since the introduction of the current fee structure, “the overall spend on fees paid to community pharmacists under the community drug schemes has continued to rise year-on-year, including by €95.7 million more in 2022 than in 2019. This is an increase of 30.5% in 2019. This indicates the substantial investment made by the Government to keep pace with the increased activity across the community drug schemes.”
Minister Donnelly continued by stating that under legislation, “the pharmacy fee structure must be reviewed every three years after 2020. Therefore, a review will take place in 2023 and work in that regard has already commenced.”
The Minister did not directly respond to Deputy Bruton’s queries on fees, instead stating that, “we greatly value the work that pharmacists and pharmacies do in terms of their place within the health and social care service”. Minister Donnelly continued; “I fully agree there is a lot more pharmacists can do and much more value they can add. We are actively pursuing various measures to that effect.”
Neasa Hourigan TD (Dublin Central, Green Party) further raised the issue of pharmacy fees to the Minister, asking for an update on “the progress made to date in respect of the programme for Government commitment to commence talks with pharmacists on a new contract and enhancement of their role in the delivery of healthcare in the community.”
In response, Minister Donnelly stated that he recognises “the significant role community pharmacists play in the delivery of patient care and acknowledge the potential for this role to be developed further in the context of healthcare service reform”. The Minister did not however, directly engage with the question posed to him by the Deputy, instead stating that, “any publicly funded pharmacy service expansion should address unmet public healthcare needs, improve access to existing public health services, and provide better value for money.”
In response to a question posed to him by Alan Dillon TD (Mayo, Fine Gael) regarding FEMPI fees, Minister Donnelly claimed that “the overall spend on fees paid to community pharmacists under the community drug schemes has continued to rise year-on-year.”
Minister Donnelly reiterated that, “Under Section 42(14) of the Public Service Pay and Pensions Act 2017 the current pharmacy fee structure must be reviewed every third years after 2020. My Department is currently carrying out a review and Department officials will communicate with the Irish Pharmacy Union in that regard very shortly.”
The Minister for Health did however remark that he believes “that there is a real opportunity to work collaboratively, and with other healthcare providers, to make a significant difference to patient outcomes.”
In both Houses of Government, the issue of expanding pharmacy services has been raised. Alan Dillon TD (Mayo, Fine Gael) made a call for pharmacy services to be expanded, stating, “it is crucial that we take immediate action to expand the role of pharmacists within our healthcare system”.
Deputy Dillon referred to the challenges faced by many individuals accessing GP service, and to address this situation he said he was “asking that the Government conduct a comprehensive review of legislation governing the role of pharmacists”.
Deputy Dillon also contrasted the sector with that of Northern Ireland, where he said, “pharmacists have dual responsibility around advising, supplying and prescribing medication. Although Irish pharmacies do not currently possess independent prescribing rights, I ask that we establish a collaborative agreement between GPs and pharmacists, as such arrangements would enable pharmacists to prescribe certain medication or make adjustments to existing prescriptions within agreed protocols.”
In the view of Deputy Dillon, this move would “streamline the prescribing process and reduce the necessity for routine GP appointments”.
David Cullinane TD (Waterford, Sinn Féin) once again raised his support for the expansion of pharmacy services, while speaking in a debate on hospital waiting lists: “There are people who cannot access out-of-hours GPs. We are not making best use of community pharmacists, particularly out-of-hours.”
The issue of the cost of pharmacy expansion has been raised to the Minister for Health by Darren O’Rourke TD (Meath East, Sinn Féin) who asked; “the estimated full-year cost of recruiting one additional WTE pharmacist chief 1, 1 WTE pharmacist chief 2, and senior pharmacist”.
In response, Minister Donnelly stated that the HSE would respond directly to the Deputy’s query.
Minister Donnelly has also highlighted his plans to expand the role of pharmacy to support GP’s, stating; “We are supporting our healthcare workers to work to the greatest extent of their training and practice through new GP programmes such as the chronic disease management programme, through advanced practice for nurses, midwives and health and social care professionals and through enhanced roles for pharmacies, where we are also working.”
The idea of greater synergy between GP’s and pharmacists, has also been raised by Colm Burke TD (Cork North Central, Fine Gael), who questioned the number of computer systems in the health system, stating; “If there are private hospitals with a different type of system, how are we working with them on this? It is likewise with the GPs and pharmacies. What is being done so all of the systems can blend together and so there are not any hitches in the sharing of information that is necessary in order to look after the patient?”
Minister Donnelly has faced a wide array of queries regarding the drugs payment scheme this month.
Social Democrats leader Holly Cairns TD (Cork South West) has queried the Minister for Health on two different aspects of the scheme. First asking the Minister, “if he will provide a separate lower rate of qualification for single-person households applying to the drugs payment scheme”, and then asking, “if he will provide details of the estimated cost of reducing the qualifying cost to €60 a month to avail of the drugs payment scheme.”
Responding to both questions together, Minister Donnelly stated, “under the DPS, no individual pays more than €80 a month towards the cost of approved prescribed medicines. The DPS significantly reduces the cost burden for people with ongoing expenditure on medicines.”
The estimated cost of reducing the DPS threshold to €60 per month is €34.8 million per annum.
Minister Donnelly continued by noting the role of the scheme, saying it was designed “as a simple universal non-means tested scheme, which is in place to protect those who do not qualify for a medical card.”
Deputy David Cullinane (Waterford, Sinn Féin) later questioned the Minister on “the status of the licensing and reimbursement of Jorveza, used to treat eosinophilic oesophagitis, on the drug payment scheme.”
Verona Murphy TD (Wexford, Independent) also questioned the Minister on the eligibility of certain drugs for the scheme, asking Minister Donnelly “the considerations his Department is giving to the inclusion of the drugs saxenda and Ozempic, both now recognised as valuable medications in the treatment of obesity, to the drugs payment scheme.”
Minister Donnelly directed both questions to the HSE.
The ongoing problem of medicine shortages has once again been topical in Leinster House. Aengus Ó Snodaigh TD (Dublin South Central, Sinn Féin) has raised the shortages of Ozempic. He told the story of the family of a young person who has been prescribed and had been taking Ozempic, until earlier this year when supplies dried up; “Their hepatology team are stressing the importance for their getting back on the drug for their health”.
In response, Minister Donnelly stated, “shortages of the diabetes medicine Ozempic are linked to the increased demand which has been attributed to the off-label use of the product to treat obesity”.
He added that Novo Nordisk, the marketing authorisation holder for Ozempic, has notified the Health Products Regulatory Authority (HPRA) of intermittent supply issues with Ozempic products due to increased global demand.
The Minister for Health continued by stating that reimbursement for the drug would be an issue for the HSE, while stating that, “Directive 2011/24/EU on patients’ rights in cross-border healthcare sets out the conditions under which a patient may travel to another EU country to receive medical care and reimbursement.”
Deputy Gerald Nash (Louth, Labour) also raised the shortages, asking “when Semaglutide will be available to diabetic patients as there currently is a shortage of this vital medication for many patients.”
In response, Minister Donnelly stated that, “The Department of Health, along with relevant experts from the HSE, HPRA, Pharmaceutical Society of Ireland and the Medical Council are continuing to work together during times of limited supply to mitigate the impact of the shortages on patients. Those patients that have been prescribed Ozempic by their doctor and are struggling to source it, are encouraged to speak to their doctor and to the pharmacies in their area as early as possible, in order to seek support in accessing appropriate treatment for their medical condition.”
Cian O’Callaghan TD (Dublin Bay North, Social Democrats) raised a similar shortage with the Minister for Health, asking, “the reasons for the ongoing shortages of the medication Concerta and the action he will take to ensure the regular supply of the medication is restored.”
Responding, Minister Donnelly explained that, “Janssen, the company that places the Concerta XL products on the market, has advised that it is encountering global supply chain issues related to component availability and increased demand in multiple markets. Supplies of Concerta XL are currently available on the Irish market. However, Janssen has stated that it is managing the supply of existing stock to ensure equitable distribution to mitigate the impact on patients in Ireland and that it is working closely with pharmacies to ensure patients receive their medication.”
Deputy Paul Kehoe (Wexford, Fine Gael) has raised the issue of HRT shortages to the Minister of Health, asking, “if he is aware of a shortage of HRT medications in the country and the measures being put in place to alleviate this shortage”.
In response, Minister Donnelly stated that shortages are “impacting multiple markets due to increased demand”. Continuing, Minister Donnelly noted that Besins Healthcare Ireland Limited anticipates resupply towards the end of June 2023”.
Addressing how his Department is tackling the shortages, Minister Donnelly noted that, “Schedule 1 of the Medicinal Products (Control of Placing on the Market) Regulations includes an exemption which enables practitioners to prescribe a medicine as an Exempt Medicinal Product (EMP) under that practitioner’s direct responsibility, in order to fulfil the special needs of that specific patient. If a valid prescription is issued for an EMP in line with the above Regulations, an appropriately authorised wholesaler can source that product from another market for supply to the patient via their pharmacy in line with that prescription.”
Deputy Eoin Ó Broin (Dublin Mid West, Sinn Féin) further raised the issue of overall shortages, asking if the Minister “is aware there is a significant shortage of some medications at the current time; if he is aware that pharmacists are unable to indicate when the issue will be resolved.”
Minister Donnelly stated, “unfortunately, medicine shortages are a feature of modern health systems worldwide which have been exacerbated by recent worldwide events”.
The Minister has faced questions about both the medical card and the possibility of a prescription card this month.
Paul McAuliffe TD (Dublin North West, Fianna Fáil) raised concern over “reports received by this Deputy that medical card holders are being denied the dispensing of prescribed Solpadeine due to shortages, despite the product being readily available for sale off the scheme in the same pharmacy store”.
Responding, Minister Donnelly confirmed that “medical card holders should be able to access Solpadeine Capsules (32 pack), subject to the payment of the statutory prescription charge. To access other Solpadeine products that are in stock but not on the reimbursement list, they would have to pay.”
Deputy Cian O’Callaghan (Dublin Bay North, Social Democrats) raised a further concern regarding the removal of “the eye-drop medication Muro” from the medical card scheme.
In response, Minister Donnelly stated, “Sodium Chloride Hypertonic (Muro) is not licensed with the HPRA in Ireland. However, Sodium Chloride Hypertonic (Muro) (ULM) Eye Drops 5% 15ml is listed as an Exempt Medicinal Product (EMP) under the community drug schemes due to the unmet clinical need. This exemption enables practitioners to prescribe a medicine as an EMP under that practitioner’s direct responsibility, in order to fulfil the special needs of that specific patient.”
Colm Burke TD (Cork North Central, Fine Gael) later raised the concept of a prescription card, asking the Minister if he would “consider setting up a working group to examine the feasibility of introducing a prescription card to record all medications issued within a particular time period”.
In response, Minister Donnelly stated, “The Department of Health identified digitisation, including ePrescribing, in the National eHealth Strategy (2013) as a key priority for Ireland, to align with the vision of bringing improved population wellbeing, health service efficiencies and economic opportunity through the use of technology enabled solutions.”
Minister Donnelly continued by saying “ePrescribing is also identified as one of the key critical eHealth and technology actions of the Sláintecare Programme. The digitisation of our health service and processes ensures that the right data about the right patient is available in the right place at the right time. There has been widespread digitisation across GP and pharmacy practices for many years in Ireland with software vendors providing solutions in each individual care setting. However, many of these systems have operated independently of each other.”
He continued, “Legislative changes made in March 2020, in the wake of the outbreak of the COVID-19 pandemic, have allowed for the transfer of prescription details between GP and pharmacies via secure email, known as Healthmail. This has been a welcome efficiency in our health service, which we need to build on.”
The IPU was referenced by Claire Kerrane TD (Roscommon-Galway, Sinn Féin) who raised an amendment in the final stage of the Veterinary Medicinal Products, Medicated Feed and Fertilisers Regulation Bill 2023. The amendment was to delete “prescription and dispensing” and substitute “prescription, dispensing and prescription endorsement”.
Deputy Kerrane stated; “This amendment was discussed at Committee Stage. We are bringing it forward again. It is an amendment we were asked to bring forward by the Irish Pharmacy Union, IPU. Pharmacists want to be reflected in the Bill. That is important. I understand the Minister has engaged with the IPU. The amendment relates to administration and record-keeping, which is important. It would allow and reflect the endorsement requirements in the Bill when pharmacists are supplying veterinary prescriptions. It is important and is something that pharmacists want. We should be led by them as professionals in this field.”
In the Seanad, Senator Lisa Chambers (Fianna Fáil) raised a concern over prices in pharmacies. The Senator said; “there is a huge disparity in pricing among pharmacies. To give an example of a very commonly used product, the Oestrogel pump pack is often prescribed with oestrogen tabs. Across three pharmacies, the price ranged from €23.59 to €33.95 and €44.12. One pharmacy is nearly double the price of the other for the same product. Pharmacies are not giving the full six-month prescription. People have to come back month on month, incurring prescription charges, additional hassle and cost that should not be there”.
Cormac Devlin TD (Dún Laoghaire, Fianna Fáil) has this month, questioned the Minister of Health on the difficulties women are facing when trying to access vital medicines for hyperemesis gravidarum.
Responding, Minister Donnelly noted that Cariban has been available through prescription from a consultant since the beginning of 2023. Continuing, the Minister of Health said, “However, on the recognition that women suffering hyperemesis gravidarum may need access to Cariban before their first consultation with their specialist/obstetrician, and in light of the fact that GPs prescribe Cariban to private patients without an initial prescription from a specialist, I asked the HSE to review the current arrangement and report back to me.” It is envisaged that this review will be completed by July 2023.
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