IRELAND AND ITS HEALTH SERVICE

Ireland has a growing and ageing population estimated to be 4.8 million in April of 2020.¹ Healthcare spending in 2018 was EUR 22.5 billion (6.9% of GDP vs 8.8% Organisation for Economic Co-operation and Development - OECD average) with 37% spent in hospitals and 18% in long-term residential facilities and 20% in out-patient providers (mainly general practitioners - GPs and dentists).² Of the overall healthcare expenditure the Government covered 74% of spending in 2018, voluntary health expenditure (mainly insurance) 14% and household out-of-pocket expenses accounted for 12%.²

Health care is provided in a mixed system with public and private practice in both primary and hospital care. All healthcare (including medicines) is provided mainly free-of-charge with some small co-payments to some eligible groups - 32.44% in 2019, the largest of which is those with low income (means tested), while all children under 6 years of age everyone aged 70 and over have an automatic entitlement to free GP services.³ People with certain conditions, such as diabetes or epilepsy, are also entitled to receive medicines and other goods for the treatment or alleviation of their condition free of charge - 6.1% of the national population were eligible in 2019.

For the rest of the population private health insurance provides cover for most of the costs of hospital care and a small proportion of other healthcare costs - a visit to a GP costs a private patient from EUR 50 to EUR 70 and for medicines the individual/family must pay up to EUR 114 per month before the Government pays any excess; in 2019 only 20.1% of the eligible population exceeded this threshold.³ The Government also pays for the cost of some oncology and hepatitis drugs and it pays pharmaceutical wholesalers for certain expensive hospital prescribed drugs that are supplied through pharmacies for which the pharmacist receives a fee. In 2019, community pharmacies received a total of EUR 1.35 billion from the government medicines schemes.³

Responsibility for policy and strategy rests with the Department of Health while the day-to-day running of Government funded health services (and some social care services) is carried out by the Health Service Executive (HSE).⁴ In primary care the policies and operation of the public health service are determined at a national level and then administered through regional offices. The health service is considered to be hospital-oriented with most of the public expenditure and public servants in the acute hospitals while primacy care receives less funding and comprises mainly private contractors.⁵

There has been a consensus among all groups in society, including politicians, that there should be Universal Health Coverage (UHC) and that the service should be more preventative rather than treatment focussed. A policy called Sláintecare has been an agreed with a 10-year implementation period.⁵ This policy does not mention community pharmacy but does accept that pharmacists, among others in Primary Care can play a part in integrated care. However, despite agreement by all the political parties and the publication of a strategy to move to UHC, progress has been slow and even the commitment to UHC by the designated reform group has been questioned.⁶ Meanwhile, piecemeal reform, rising consultation rates and rising costs create frequent crises that the Department and the HSE must attempt to manage.

PRIMARY CARE

In Ireland, patients may access primary care providers through the public health service or from a private provider. GPs, dentists and community pharmacists contract with the HSE to provide its services to public patients but they may simultaneously provide private services. In this way private practice is prevalent throughout primary care and successive governments have wrestled with the problems of providing resources to extend and improve the practices of health professionals without these resources being used for private instead of public patients. Private practice also offers opportunities for health professionals to induce demand among their patients.⁷ Contract negotiations are usually difficult and protracted as each side tries to gain advantages and as each professional group protects its members interests against the activities of other professionals which they view as encroaching upon their domain. For example, GPs compete to assess and treat private patients with hospitals and community pharmacists.

In a national population survey, 84% perceive their health to be very good or good and 32% report that they currently have a long-standing illness or health condition such as, high blood pressure (13%), high cholesterol (10%) and arthritis (10%).⁸ Public patients visit GPs more than twice as often as private patients and 27% of those reported affordability issues compared to 6% of public patients.⁸

GPs wield considerable influence as they are the gatekeepers of the public health service which means they determine who needs to visit a specialist in hospital or is entitled to certain health and social care services. General practice evolved in Ireland with many single-handed practices which increasingly lacked the capacity to respond to the rising prevalence of multi-morbidity and the need for sophisticated investigations. GPs who hold contracts with the State (2,974 in 2019) receive a capitation fee for treating public patients and are operate fee-for-service with their private patients.³ Community pharmacists are reimbursed for prescription products and are paid a dispensing fee for public patients and for private patients charge for the cost of the medicine plus a dispensing fee - there are no mark ups on the cost of medicines. Pharmacists may substitute a generic medicine and are only paid for a generic irrespective of what is dispensed under a government scheme or for private patients unless they wish to pay for a particular brand. Value added tax must be charged on some items. In 2019, 79,269,467 items were claimed for by community pharmacies.

Community pharmacists sought to develop patient medication records to be able to follow up patients and to monitor prescription medicines usage, at first using record cards. The health service wanted accurate and timely data on its medicines schemes volumes and costs resulting from claims and wholesalers wanted to track their pharmacy clients' orders. These two factors propelled computerisation in community pharmacy earlier and more profoundly than in other professional groups in Ireland.⁹

Since 2001 the HSE has sought to organise GPs into primary care teams to serve populations of 7,000-10,000 and to co-locate other professionals such as physiotherapy, practice nurses and speech and language therapists with them in health centres to increase the integration of the care provided.¹⁰ During the development and implementation of this policy neither community pharmacists nor dentists wanted to join these teams arguing that their practice populations did not coincide with those of the team and because GPs were likely to be the de facto team leaders. Primary Care Networks were also proposed as looser linked groups in which dentists and community pharmacists would take part, but these were never implemented.¹⁰ Initially the health centres were all government funded but recently public-private partnerships and other approaches have become acceptable. In 2019 the new GP contract provided significant additional funding for general practice and placed the topic of medicines optimisation on the agenda for development in the near-to-mid-term which links with the GPs' proposals for ‘clinical pharmacists' working under their direction.¹¹

As in other countries, successive Irish governments have frequently attempted to influence prescribing in primary care through a variety of methods; in order to promote the prescribing of generics the Health Products Regulatory Agency (HPRA; Medicines Regulator) regularly publishes lists of interchangeable medicines; while in frequently prescribed and costly therapeutic areas particular drugs are designated as ‘Preferred Drugs' and they determine which products will be reimbursed and for which indications in the different medicines schemes.¹²-¹⁴ The resulting complex framework of schemes, differing eligibility and controls of access to medicines causes confusion amongst prescribers and patients and together with an increase in the prevalence of medicines shortages that has been exacerbated by disruption due to preparations for Brexit and the Covid-19 pandemic, all of this has added to the workload of the community pharmacist explaining and advising patients and prescribers about who is entitled and to what they are entitled.

Prescribing in primary care is heavily influenced by hospital prescribing policies particularly in those patients with multiple morbidity who represent a growing segment of the Irish population. Hospital prescriptions must be transcribed onto a prescription appropriate for the government scheme in Primary Care in order for the patient to receive the medicines without additional costs. GPs complain that communication with hospital prescribers can be difficult and not all of them are prepared to question or intervene if these prescriptions contain anomalies or potentially conflict with other prescriptions that the patient has been given. Since the pharmacist must assure themselves that the prescription is ‘in the patient's best interest' it is left to them to intervene and notably, pharmacists may refuse to dispense such a prescription for public patient and will still be remunerated.¹⁵

The organisation of care in residential homes for elderly and disabled people ranges from substantial in-house provision to periodic visits from contracted medical and nursing staff while community pharmacies provide the medicines usually in a manual monitored dosage system. However, despite guidance about patient counselling and the need for regular interdisciplinary meetings to review patient's medicines, these aspects of the care process are poorly monitored and enforced.¹⁶,¹⁷

One area of practice in which there is a significant degree of collaborative practice is that of addiction services.¹⁸ Clinical guidelines for opioid substitution are based on a service in which users must register with participating prescribers and pharmacies to receive their medicines and the roles and responsibilities of all the participants are clearly set out. The HSE employs Liaison pharmacists to assist with the organisation and to support GPs and pharmacists in the operation of the scheme.

COMMUNITY PHARMACY

Community pharmacies are regulated under the title of retail pharmacies by a regulator, the Pharmaceutical Society of Ireland (PSI), with the power to make regulations, issue guidance, inspect premises, publish a code of conduct and assess the fitness-to-practice of a pharmacist working in a retail pharmacy business and to apply a range of sanctions.¹⁹ It is the most frequently consulted organisation in the pharmacy sector and its perspective is that of a State regulatory body. However, the regulator is limited to pharmacies that contract to provide medicines under government funded schemes and so the care of hospital inpatients is not within its remit. Since the formation of the pharmacy regulator there has been no professional body to represent pharmacists which diminishes the voice of the profession and hampers its development.²⁰ The Irish Pharmacy Union (IPU) represents the majority of pharmacy owners (~95%) both chains and individuals and some employees.²¹ They negotiate the contract with the HSE and advocate on behalf of community pharmacy. The IPU has developed resources, applications and cloud services for use by community pharmacies. They have sought to introduce new services and they support the continuing professional development of pharmacists and pharmacy technicians through education and meetings.

In October of 2020 there were 1,891 community pharmacies and 3,804 pharmacists registered as community practitioners with the pharmacy regulator in 2020.²² Community pharmacies can be owned by individuals or by limited companies and there is no limit on the number that may be owned. A pharmacist must be appointed to supervise the day-to-day running of a pharmacy (supervising pharmacist) and where there is more than one pharmacy a superintendent pharmacist must be given the responsibility and resources to supervise the supervising pharmacists.²³ Pharmacy Technicians may assist in dispensing and the provision of non-prescription medicines under the supervision of the pharmacist but may not substitute for the pharmacist. Consequently, there are large and small chains as well as individual pharmacies in Ireland and since there are no criteria to regulate the distribution of pharmacies Ireland has one of the lowest populations per pharmacy figures in the world, 2,538 in 2020. Recently, a discount medicine supply pharmacy group has been established and another is considering entering the sector. There is significant competition between chains, discount providers and independents especially around the price of frequently used prescription and non-prescription medicines and additional, potentially fee-bearing services such as the provision of manual monitored dose systems.

Prescription medicines may not be promoted to the public and can only be obtained from pharmacies - mail order and internet supply are not allowed. Non-prescription medicines are classified as either pharmacy-only or general/open sale (‘grocery outlets' only) and these may be promoted to the public. Some can also be provided by internet suppliers entitled to use the EU common logo; in 2020 there were 112 pharmacies and 80 other suppliers registered.²⁴ However, some classes of non-prescription medicine may not be available for self-selection in pharmacies - this guidance, from the Pharmacy Regulator not the Medicines Regulator, applies to codeine-containing non-prescription medicines and to domperidone, and is enforced via the pharmacy regulator's inspectors.²⁵

FUTURE

CONCLUDING REMARKS

For both community pharmacy and primary care the health service's mixed public-private system results in increased costs, fragmentation of service provision and competition for private patients.⁴⁹ At the system level, primary care is treated as a collection of appointment-based services and very little data is collected routinely to monitor the usage of these services by private as well as pubic patients. Community pharmacy is neither included in reviews of the system nor when data is collected. As a consequence, because policy makers have an incomplete understanding of how patient's perceive and respond to their health concerns and how they view and use medicines, they cannot begin to deliver Sláintecare's aim of right care, right place, right time. The central focus of the Department and of the HSE remains on tracking and accounting for the cost of medicines and the operation of the medicines schemes with the result that community pharmacy is treated as a supply service and the defects in the medicines use process are undetected and unrecognised. The government therefore approaches the use of medicines as a prescribing problem and gives no thought to bringing together the stakeholders and services to formulate a national medicines policy for Ireland.⁵⁰ To implement Sláintecare will require an increase in the proportion of GDP committed to health expenditure, whether, and when, this might happen, now that the Covid-19 pandemic has created additional demands for expenditure and decreased government revenue, is unclear.

In a comprehensive review of the reform process it has been argued that because a definition of the term ‘integration' has not been agreed by stakeholders as the health service attempts to reform, that this acts as a barrier to the process.⁵¹ This, together with the existing organisational culture of separation and lack of collaboration impedes interprofessional contacts and disrupts the provision of care. Medical dominance persists with health service managers deferring to the medical organisations in the nature and extent of integration. GPs have defended their scope of practice from what they see as encroachment and are trying to add a pharmacist funded by the HSE to their practice team since this will increase their capability. There have been no substantive moves to include community pharmacy in integration, or to establish communication mechanisms in primary care. Unless the eHealth strategy gives pharmacists access to, and the authority to contribute to, the national electronic patient summary, then community pharmacy will be limited to informal and uninformed interventions to optimise patient's medications.

Pharmacies and pharmacists retain the trust of the public and have utilised digital technology effectively to support their practices. However, community pharmacists have concentrated on delivering services when and where they can and they have been unable to alter the perception of them as managers of medicines rather than as providers of care. The HSE's and the pharmacy regulator's terminology and approach has reinforced and perpetuated this perception. The lack of a professional body that is independent of any trade representative function has contributed to the weakness of the pharmacists' position. Since the income of community pharmacy derives mainly from the medicines schemes and each government reduces that income, pharmacists have had to gain volume and increase turnover to ensure the commercial viability of their practices with less time and resources to commit to individual patient care and service development. The policies and reforms of the Department of Health and of the HSE, under pressure from the medical organisations, has helped to drive this change in pharmacy practice. While this outcome may have been unintended, it was not unpredictable.

Pharmacy is more highly regulated in Ireland than any other health profession and operates to a very high standard. While it can be held accountable, it has only limited authority to enable it to meet its obligations and this frustrates many and demoralises some within the profession and this combined with the horizontal and vertical consolidation within the pharmacy sector may deter those who wish to care for patients from entering community pharmacy and encourage the departure of those who are trying to do so at the moment.⁵²

The optimisation of the use of medicines by individuals and within the health service depends upon the pharmacist establishing a therapeutic relationship and upon a comprehensive national medicines policy. In Ireland, as elsewhere, commitment by pharmacists to the provision of pharmaceutical care will deliver this optimisation for the benefit of their patients and their health service.⁵³