We hear stories about a drug shortage protocol, or as the Department are referring to it, the Medicine Substitution Protocols, but it is hard to know if this is an illusion or a genuine attempt at a solution. On any given day, the exasperation of reaching for another absent product has become a seriously discordant note. Wrapped up in all this dysfunction is that this mess could, at least, be mitigated by a reasonable response from the HSE and the Department of Health with more timely proactive measures to address this growing issue. Ironically, last year the Department published a report, which they had commissioned from Mazars, to assess their governance arrangements to support the HSE reimbursement process. It is a real pity that they didn’t include the patient, pharmacist or prescriber in their contemplations, and the impact that these reimbursement policies have on the patients and healthcare professionals trying to navigate what is becoming an administration gauntlet. It has echoes of the reports junior executives used to write in previous decades, telling the bosses what a great job they are doing. Regardless, in my opinion, we have created an alternate drug market at wholesale level, where a range of expensive unlicensed alternatives are offered as Hobson’s choice to address shortages.

One aspect that I cannot help noticing is how many drugs for older people are affected, none of which will be reimbursed by the State. For instance, there is no licensed digoxin tablet on the Irish market. This is, apparently, directly a result of a pricing standoff between the State and the supplier of the only licensed product, Lanoxin. This drug is no longer a mainstay of treating heart failure, so its market share has collapsed over the last few decades. The economics of this are fairly obvious. The drug remains cheap, still costing a fraction of other heart failure drugs. But the State will not allow an economic price increase. Generally, people on digoxin are older, unwell and unlikely to be major political agitators. It seems, from my perspective, that there is little appreciation of the direct effects of this common scenario on poorer, older patients. On a similar vein, I was recently shocked to discover that the State will not pay for lidocaine patches for terminally ill patients. This directly leads to charities having to fund these. There is something deeply dysfunctional in a system that refuses to pay for medicines that have been demonstrated to ease pain in a very small number of palliative care patients. This is despite, on the other hand, an almost automatic coverage for many other medicines, for these same patients, under the dysfunctional hardship scheme. This whole area could be safely described as another fine mess. We saw recently where licenced versions were simply unavailable of morphine, midazolam and other key essential drugs. Pharmacists were forced to procure expensive unlicensed alternatives. It is unreasonable to ask pharmacists to shoulder this burden, particularly when there is an obvious solution. Specialist palliative care settings are widely available in many parts of the country. Many, like in Kerry, have been developed in conjunction with the HSE solely through local fund-raising efforts. It is, evidently, beyond the ability of the HSE to deliver on a core palliative care formulary.

I hope that my early enthusiasm for the Ministerial pronouncements at the IPU conference are not misplaced. The first official decision, following a recommendation from the expert group, has been the proposal to allow pharmacists to extend prescription validity to a year. The terms and conditions are still to be declared. It is hard to work up any enthusiasm for this rule change, as I had initially thought it had all the hallmarks of a decision reached after a dinner party. You can imagine the conversation, a group of private patients grumbling about having to pay a doctor to renew their prescriptions, without any perceived meaningful value added. Therein lies a conundrum for community pharmacy. There is the obvious temptation to view this as simply a cost saving mechanism. When the announcement, sans details, was made, some newspapers interpreted it as free prescription renewals. I think that this is a completely inappropriate and utterly wrong way of viewing this. For many decades, the vision of doctors diagnosing and pharmacists treating has been seen as a progressive and sustainable use of scarce medical resources. We now are at a nexus. Do we see the extension of prescriptions as simply an administrative function or as an opportunity to deliver meaningful additional care to our patients? I know that many pharmacists are already stretched and would find it difficult to safely deliver prescription extension services. Yet, it is clear that computerisation and automation will gradually shoulder much of the routine dispensing burden. It is incumbent upon the profession to deliverer a workable model that will ensure pharmacists, and pharmacies, continue to provide the exceptional care that we know we give every day. So, as I think about the Ministerial pronouncement more, I know see it as a potential key step in the empowering of the profession for the future.