Coverage and exclusive interviews

Pharmacy without borders

The 9th All-Ireland Pharmacy Healthcare Conference was opened and chaired by Dr Catriona Bradley, IIOP Executive Director, who introduced Ms Kate Mulvenna, Chief Pharmacist at the HSE, who delivered the opening address. The attendees also heard an introduction from Prof Colin Adair, Director of the NI Centre for Pharmacy Learning and Development at Queen’s University, Belfast. Prof Adair pointed out that the conference played host to more than 100 presentations, including parallel sessions, on a diverse range of clinical topics relevant to pharmacists from both north and south of the border.

Ms Mulvenna drew attention to the various examples of good practice highlighted at the conference, which were drawn from various different settings and while pharmacists and organisations must focus on the future and where the profession needs to be, “we also have to remember where we have come from and bring with us what’s best, and incrementally change as we develop our own skills, our team skills, and our own inter-connectivity with other members of the wider healthcare team,” she said.

Ms Mulvenna told the attendees: “Perhaps one of the things as pharmacists that we don’t leverage enough is our IT capability, because that is how we engage structurally, and not just personally, but also in terms of how our systems engage with other systems in the wider landscape.”

She continued: “The development of a research evidence base is essential and for it to have currency, research must be situated in the context of peer review, sophisticated methodology and highly-trained researchers,” she said. “Some structures are better in the north of the island around those elements of research, but the south is catching up fast and there are more and more opportunities in the south now.”

She highlighted the examples of innovation provided by the conference that may inspire other pharmacists to enhance their own practices. “It’s important for us to improve, for all professional groups to consider how to use their own specialist skills and to have confidence in those skills and use that knowledge and expertise to support the health improvement agenda and improve quality of care, wherever they fit into the patient journey,” said Ms Mulvenna. 

She also emphasised the importance of pharmacists in maximising benefits and minimising risks in the use of medicines. “We know that prescribing is the most frequent healthcare intervention; we know the rising costs of medicines exercise the minds of budget-holders — they can actually put a figure on how much medicines cost, but we don’t spend enough time thinking about how the experts in medicines use can make sure that we get more value out of that existing cost.” 

Research has shown a certain amount of discontentment, particularly in the community pharmacy sector both north and south, added Ms Mulvenna. “That’s challenging to address but before one can make inroads to change this, it’s important to understand what’s behind that emerging theme,” she said.   

In terms of chronic disease, “we spend so much time giving lip-service to how we can improve the preventative health agenda but simply put, it’s a hard thing to do in a way that the research will signpost it.” 

Tackling the national and global challenges

The 9th All-Ireland Pharmacy Healthcare Conference was the best-attended of the conferences yet and was organised by the Irish Institute of Pharmacy (IIOP) and was held to coincide with International Pharmacy Technicians Day. This year, the attendees heard the keynote address delivered by Dr Catherine Duggan, CEO of the International Pharmaceutical Federation (FIP), who spoke on the theme ‘Delivering the WHO Primary Health Care Agenda: Strategies to Meet National Care Needs through Pharmaceutical Workforce Transformation’.

Ms Duggan began by stating: “I would really welcome any ideas today… there is something about the nature of Ireland that means you can learn from each other, but it’s also small enough that you can effect change. There are other countries in the world that would love to learn from Ireland.”

Ms Duggan told the attendees that the “selling point of the FIP is its relationship with the WHO” and explained that it is important to maximise such relationships, such as with the UN, the Gates Foundation, the Clinton Foundation and others in order to “add value to the FIP”.

“It’s 40 years since the Declaration of Alma-Ata,” she continued. “We have made a lot of progress in that 40 years, but you could say it’s not good enough to be just ‘good enough’. When you look at the variances in education you see in our profession, when you look at the changing needs of patients, even over your own career — for example, when I qualified, the average number of medicines a patient was being prescribed was between five and six, and the average age of elderly patients was early 60s. 

“Now, we have patients who are being prescribed 30-to-40 medicines and they are in their late 70s. That’s a success and means our patient populations are living into an older age. Are they living well into older age, and is taking 30 medicines a sign of success, or a sign that we could be doing more?” she asked.

Ms Duggan also highlighted the ever-increasing importance of pharmacists to the healthcare system. “That patient is increasingly complex, as is the cocktail of medicines they are prescribed,” she said. “Costs are rising, and no country has quite got this right. The concept of universal health coverage is a very trying one for many countries. So we have to be honest, we have to be able to afford the care that we promise to the public and we have to be able to provide ways to deliver it.”

She also revealed the FIP will be acting as a ‘neutral partner’ in discussions about medicines pricing and affordability, in conjunction with discussions about remuneration and services, which Ms Duggan described as a “quid pro quo”.

Ms Duggan also provided an overview of data from the Pharmacy Workforce Intelligence: Global Trends Report 2018 by the FIP, the only document to provide such data covering 10 years, a fact that was acknowledged by the WHO.

Referring to Northern Ireland and the Republic, she told the conference: “The female proportion of pharmacists will continue to increase to around 72 per cent by 2030,” said Ms Duggan. “That doesn’t mean the workforce is becoming ‘feminised’, it means we have more females working in our profession and we have to think about how we are going to manage that. We are not the only ones who have that conundrum of change — the medics are really struggling with this, also nurses, dentists, physical therapists, and so on.” 

There will also be an estimated 40 per cent growth in capacity by 2030, explained Ms Duggan. “I’m sure all of you have already increased your capacity to do more and when we look at the patient need and patient burden, there are more medicines being prescribed, more patient burden, and we need to think about how  we are going to manage that effectively and with impact.”

Ms Duggan summarised her take-home messages by telling the conference: “There is a clear imperative to face-up to more global and national challenges,” she told the attendees. “But if we do that, sometimes it can feel overwhelming, so sometimes it’s a good idea for our national associations to take positive action to support workforce development.

“Pharmacists must rise to both healthcare challenges and career challenges, and I think both can go hand-in-hand,” she continued. “Wouldn’t it be great if we could look back at the end of our careers and think, ‘I have made a difference’… but there is no pharmacy healthcare without a highly-skilled, flexible and capable pharmacy workforce — no country is immune to these challenges.”

PIPs ‘honestly indispensable’ on hospital wards 

The 9th All-Ireland Pharmacy Healthcare Conference featured an extensive range of research presentations, as well as parallel sessions on ‘Advanced Practice and Specialisation’, ‘Working with Others’, ‘Competency Development’, and ‘Workforce Impact’. The conference organisers also placed the poster presentations in the same room as the talks that were presented, in order to allow easier and more informal access for attendees to the research on display.

Among the presentations was research titled ‘Are Pharmacist-Written Discharge Prescriptions Making a Difference?’ from researchers at the Pharmacy Department and medical staff in the South Eastern Trust, Belfast.

This research saw Pharmacy Independent Prescribers (PIPs) writing discharge letters in three wards in Ulster Hospital. 

The questionnaire-led research showed that 100 per cent of respondents were aware that there was a PIP available on their ward and 100 per cent also ‘strongly agreed’ that they would support the roll-out of the service to other wards. In addition, senior medical staff noted fewer queries arising from primary care  post-discharge. One junior doctor commented, “the PIP is honestly indispensable, freeing me up to see sick patients, and ultimately improves patient care on this ward”.

The authors concluded that “the results from the questionnaire displayed overwhelming support for the PIP writing discharge letters”. 

Pharmacists in residential care ‘positively improved patient outcomes’

Research at the 9th All-Ireland Pharmacy Healthcare Conference highlighted the benefits of having pharmacist expertise in the residential care unit and was conducted by researchers both north and south of the border, at Our Lady’s Hospice and Care Services in Harold’s Cross, Dublin, and Pharmacy and Medicines Management, Northern Health and Social Care Trust and Regional Medicines Optimisation Innovation Centre, Antrim.

This study involved an 80-bed residential care unit in terms of quantifying the number and type of pharmacist interventions made and their acceptance rate, and assessing the impact of pharmacist interventions on patient care. 

The authors also looked at staff attitudes towards the clinical pharmacist service.

Over 10 weeks, there were 615 pharmacist interventions, comprising drug therapy review (34 per cent), technical prescription (26.5 per cent), administration (15.3 per cent), drug interaction (10.4 per cent), and medications reconciliation (8.5 per cent). 

Ninety-eight per cent of interventions were rated as having significance to patient care and of the interventions that required acceptance by the medical team, 89.9 per cent were accepted.

“The pharmacist has an important role to play in our residential care unit,” concluded the authors. 

“Their involvement in the medicines optimisation process positively impacts patient outcomes and prevents harm. Staff perceived a positive impact of the clinical pharmacist service provided on patient care and patient safety.”

PSI ‘needs to adopt more responsive approach’ for better regulation

Research presented at the 9th All-Ireland Pharmacy Healthcare Conference, conducted by Mr Matthew Lynch at the RCSI School of Pharmacy, showed that while the need for the Pharmacy Act 2007 is acknowledged, there is a sense among community pharmacists that the regulator needs to be more responsive.

Twenty community pharmacists participated in one-to-one interviews to assess their experience of the Act and its implementation by the PSI. In general, the pharmacists interviewed did not see the Act and its implementation by the PSI as “fulfilling the principles of better regulation”. However, there was general agreement that the ACT is necessary, but the respondents “did not view its implementation as effective, targeted, proportional, transparent and consistent” and felt that the PSI was not sufficiently accountable for “the discharge of its statutory duties under the Act”, while the act itself was seen as “not sufficiently agile to respond to the ongoing changes in pharmacy practice”.

“The principles of better regulation provide an effective methodology to qualitatively study models of professional regulation,” wrote the author. “The study findings are of interest, as there is little research published on how those who are subject to regulation experience its provisions.”

PPIs and statins most frequently requested for non-substitution

Research presented at the 9th All-Ireland Pharmacy Healthcare Conference showed that community pharmacists overall have positive opinions and experiences around generic substitution, however patients’ attitudes remain a challenge and statins and proton pump inhibitors (PPIs) were most often requested for non-substitution by patients.

The research was conducted by staff at the School of Pharmacy and Pharmaceutical Sciences at Trinity College Dublin and looked at medicines that are deemed safely interchangeable and community pharmacists’ perceptions of both prescriber and patient reasoning for non-substitution. An anonymous online survey gathered the opinions of 120 independent pharmacies in 22 counties in Ireland and it was found that pharmacists have confidence in performing generic substitution. However, obstacles include narrow therapeutic index, hypersensitivity to excipients and “patient mistrust in generic medicines was a major barrier to patient acceptance,” wrote the authors. 

While 86.5 per cent of generic substitution recommendations by pharmacists were well accepted by patients, “concerns were evident relating to patient acceptability, hypersensitivity, patient confusion and patient and prescriber mistrust in generic equivalence,” they wrote. PPIs and statins were the two most frequently requested medicines for non-substitution. “Communication and education are two key interventions that will help maximise generic substitution in Ireland.”

Brexit ‘not just an EU/UK issue’ — FIP CEO

In an exclusive interview with Irish Pharmacist (IP) at the recent 9th All-Ireland Pharmacy Healthcare Conference, CEO of the International Pharmaceutical Federation (FIP) Dr Catherine Duggan said that while uncertainty over Brexit is generally regarded as an EU/UK issue, “it is raising a lot of issues that we can see are cascading into other areas of our thinking, like shortages and supply and how we will manage access to medicines, for example, as well as movement of workforce issues — all of these are really pertinent to pharmacy. 

“Everybody is keeping their fingers crossed that something will be pulled out of the bag, whether that is a last-minute deal or a new way of thinking about it. We [FIP] will need to think carefully about the workforce in the UK and Europe, as we do globally.”

She added: “That has added a complexity that perhaps people may not have planned for. A person’s qualifications will count, because they have adhered to all of the EU policies — the practicalities of somebody doing an internship in another country and coming back could be quite detrimental.” 

Dr Duggan was also asked about the challenges in building partnerships with organisations like the WHO, and whether the benefit of involving pharmacists more comprehensively in healthcare policy is fully understood. 

“Having the time to explain these issues [to other organisations] is the number-one factor,” she told IP. “In our conversations with Dr Tedros [Director-General, WHO], my husband came with me and he’s a community pharmacist and has run a national organisation in Switzerland. We thought we would have 20 minutes with Dr Tedros but we actually spent one-and-a-half hours. When we came in with an aligned argument about how pharmacy can support the delivery of these agenda items, and understanding that medics are quite threatened by health worker shortages, we went in with a solution-based mindset. 

“When we got to the nub of the issues, we were saying that pharmacists often feel a lack of recognition and lack of remuneration. We also pointed out that this often results in a lack of self-esteem in the profession and he said he was going to help us with that, so we will have a health ministers summit in 2022. We will need to have evidence by then of the impact being across health regions in the world — we don’t want ministers in a room hearing what we can do; we want them to be able to see what we have done.”

A meeting of finance ministers is also planned within the next year or two and pharmacists will be a value-adding solution for these ministers, Dr Duggan added.

Synergy and energy north and south

In an exclusive interview with Irish Pharmacist (IP) at the recent 9th All-Ireland Pharmacy Healthcare Conference, Dr Catriona Bradley, IIOP Executive Director, said the annual conference serves an important, specific purpose in bringing pharmacists from north and south of the border together.

“It’s a lovely environment where we can have colleagues from all over the island and there is great learning across the jurisdictions. There is a lot of commonality — we are all working on the beautiful island of Ireland, but we are working across two jurisdictions. When you know somebody just up the road over the border is doing things very differently, there is a certain comfort in that, knowing that they are pushing the boundaries of practice,” said Dr Bradley. “But there can also be some frustration if people feel that their system is not evolving quickly enough in comparison to another. So we just need to leverage, have more synergy, learn from each other, but one of the nice niche aspects of this conference is its collegiality, cohesion, and connection on personal and professional levels and that’s needed in pharmacy because we don’t have enough of it,” she explained.

Relationships

“We do tend to over-theorise sometimes and at the end of the day, change comes down to relationships… it ultimately comes down to individuals sitting at a table and how they have come to know each other,” Dr Bradley told IP. “We talk a lot about the evidence and that is very important indeed, but at the end of the day, driving change comes down to relationships. We need to be more mindful of that in pharmacy.” She was also asked whether the conference takes on extra significance against the backdrop of the ongoing chaos around Brexit. “That hasn’t come up as a topic at the conference but we do all know that it’s there,” she said. 

“It is being discussed by the right people in the right places but at a practitioner level, you still have to look after your own patients, and at the end of the day we will all have to work harder to ensure that those relationships are not damaged by any potential fallout from Brexit. Because the focus here at the conference is very much about contact and connections, that’s exactly what we have been doing. 

“I suppose it’s ironic that the subject has not dominated a north-south conference; that’s not to say it’s not important, but also, a lot of people simply have Brexit fatigue.” Inclusion, collegiality and the common cause of patient care are what dominate the conference, Dr Bradley explained. 

Recognition

Also bearing in mind the international flavour of the conference, Dr Bradley was asked whether she felt pharmacists in Ireland are behind their colleagues in other jurisdictions in terms of recognition as a profession. “’Recognition’ is an interesting word, in the context of recognition by whom, for example,” she replied. “If we talk about recognition by patients, I think they do recognise what pharmacists do for them. In terms of authorities, I don’t think we should be too negative — there is actually some really good recognition of pharmacists. We have what’s termed ‘professional pessimism’, which makes us brilliant in our roles. This means that we approach issues, identify the problems and try to sort them, which is fantastic when you are dealing with clinical issues but actually, if you take a holistic look at it, we often don’t stop and celebrate the positives. You need that to build resilience or otherwise you can focus too much on problems and forget to celebrate, and leverage, the positives.

“I think there is a lot of recognition for pharmacists here at the level of policy-makers, and it’s a growing recognition that we need to deliver care at the lowest level of complexity close to the patient’s home, having primary care becoming a prime focus. They [policy-makers] know this, but I’m not sure they know how to leverage pharmacy to achieve their goals just yet.” She continued: “So in terms of recognition, if you interpret that by asking if we have had the opportunity to operate at the top of our scope of practice, I would say not yet,” said Dr Bradley. “But I am hopeful that if we make the right relationships, work on the right messages, talk about the positives and present the evidence to the right people at the right time, it will happen. If we create the right environment, when it does happen, we will be ready.”

Success

Dr Bradley was also asked about her hopes and aspirations for the future of the IIOP. “The Institute was set up according to the 2010 report, with a vision for it to lead advanced practice and to lead where pharmacy is going,” she explained. “It has been extremely successful on a number of fronts, including CPD; it is a service agreement, so the RCSI delivers the service that the regulator requires us to and at the moment, for the current contract, that service is very much focused on delivering CPD, quality assurance of CPD, and quality assurance of practice. 

“So there isn’t a formal mandate to advance practice at the moment, but what it does do is bring together hundreds of pharmacists with a peer-support network and they are nudging in a few different directions… the Institute will do what it is contracted to do but it will also be an enabler for change for other agents and play its part in the world of pharmacy,” she told IP. She also touched on a “really exciting” project with the RCSI, in leading the Life-Long Learning Agenda for all practices, including surgery, medicine, pharmacy, nursing and physiotherapy, which is focused on how to create a conducive life-long learning agenda for healthcare practitioners, “and that’s a really stimulating and important initiative,” she added.

Evaluating aspirin use in CVD in older adults

Research showcased at the 9th All-Ireland Pharmacy Healthcare Conference drew on the Irish Longitudinal Study On Ageing at Trinity College Dublin and the HRB Centre for Primary Care Research at the RCSI for a study titled ‘Characterising Aspirin Use in Cardiovascular Disease (CVD) in Community-Dwelling Middle-Aged and Older Adults in Ireland’.

The authors looked at how guidelines have varied over time with regard to recommendations on aspirin use in cardiovascular treatment and disease prevention and the current use of aspirin use in people aged ≥50 years. Some 6,618 adults were included and prescribed aspirin was reported by 55.6 per cent of users, with 1,432 participants and 77.6 per cent of aspirin users having no previous CVD. Among those with previous CVD, 17 per cent were not prescribed aspirin or another antithrombotic.

The authors found that in those without CVD, older age, male sex, medical/GP visit card eligibility and more GP visits were associated with aspirin prescribing. In addition, for participants who underwent a health assessment, mean Framingham CVD risk was greater in those prescribed aspirin compared to non-users, at 21.4 per cent and 14.6 per cent, respectively. Cardiovascular risk was significantly associated with aspirin use after adjustment for demographic factors. 

“We estimate that one-fifth of people aged ≥50 years on aspirin have no previous CVD,” wrote the authors. “This may reflect a legacy of historical guideline recommendations which have now changed.”