Ultan Molloy discusses whether some recent developments will turn out to be good for pharmacists and their patients
What a big month September was for Irish pharmacy. The change in ownership of Hickey’s 36 pharmacies looks likely, with one of the two main wholesalers getting deeper into the sector. Cara pharmacies had an interim examiner appointed. Community pharmacists have had our scope of practice extended, so that we can now offer the flu vaccination to children this coming season. So, how’s all this playing out then? Will it be good for pharmacy, pharmacists and most importantly, for our patients?
Hickey’s — another ‘bite in the neck’ for independent pharmacy?
Hickey’s being bought by one of the wholesalers in the present duopoly reads well for Uniphar, assuming they’re not heading down the road of another IPOS debacle and have overpaid for it. Vertical integration is a sensible strategy of course for the wholesaler, and given that United Drug owns Lloyds, it’s not an unfamiliar approach in the Irish community pharmacy market. Uniphar says that it now has about 330 pharmacies that are owned by it, or in its symbol groups, which will be good for stickiness/loyalty and turnover, although its business strategy sees the wholesale element of its business contributing proportionally less year-on-year to the company’s turnover and profitability as it moves forward.
It’s probably not great, however, for the majority of pharmacy businesses, as the duopoly of wholesalers will have more of a foothold in the market at a customer-facing level. Competing with your wholesaler’s business, or potentially businesses (ie, if you happen to have a Hickey’s and a Lloyds nearby and run two wholesaler accounts), down the road, is ironically akin to competing with oneself through one’s wholesaler purchasing.
Cara — sure, aren’t we all friends here?
Our colleagues in Cara pharmacies are going through a rough time. The company has been loss-making for a number of years and now appears to be in trouble on a number of fronts. A pricing strategy that appears not to have lived up to what it needed to, premium stockholding and stock control issues (now, aren’t we all familiar with those), rent and other overheads, wage inflation, more especially in recent years, and investors who at board level appear to have shown little scrutiny and analysis for a time, and more getting into something akin to a panic when they realised that the Titanic was indeed heading for the iceberg that outsiders looking in could have pointed out was a risk to the whole board some time back.
There is something fundamentally human about sunk cost bias, so please do not take it that I am gloating, or take any pleasure from seeing colleagues in trouble. Rather, I see it as a warning to the rest of us to remember the value of dissenting voices and to cut our cloth to suit our measure. I do not know the composition of the Cara’s company boards, but I very much doubt that there was an investment made in any number of independent non-executive directors.
The majority of community pharmacies are limited companies, and directors, who are often the major shareholders, also are there by law to serve the best interests of the company. Friendly investment partners, no doubt committed as directors at board level, appear to have remained just that; friendly. Friendly, until things may have gone too far to be fixed. A real friend would have challenged the strategy, dug into the market, looked at KPIs and precedent, market trends, and undertaken appropriate and diligent annual analyses in a spirit of trust and healthy conflict, challenging group-think, assessing a risk register, and ensuring the company was sensibly mitigating against them.
Time will tell how this one plays out. I just hope for the owners, the 160 staff, and the thousands of patients involved, that it’s as painless as can be reasonably expected. To Elm Corporate Credit DAC, well, you knew what you were getting yourselves into. You should have applied appropriate corporate governance and oversight. That should have been your area of expertise. Yes, that would have taken some effort and difficult conversations, but it would have added value, and could have protected your investment and served the company well.
Flu vaccination — sure, why would you bother with that?
The upside of pharmacist involvement has seen a 60 per cent increase in the uptake of flu vaccinations over the last 10 years, many of these given through pharmacies, but also no doubt due to some healthy competitive tension with GP practices and other pharmacies driving uptake volumes. Still, 4,000 or so people ended up in hospital during the last flu season, so there is more work to be done.
So the initiative, and pharmacists’ involvement, has delivered for patients, no doubt keeping hundreds out of hospitals and GP surgeries. It has delivered in terms of vaccine uptake and overall public health. It has seen a review of the vaccination fees paid to GPs and a resulting significant reduction, with ‘sure, can’t the pharmacists do it for less?’ no doubt implied, leading to savings there for the State. What has it meant for pharmacists, however, other than some goodwill with patients, and putting significant strain on the relationship with some local GP practices?
It certainly hasn’t delivered financially so that we can effectively resource our businesses. As of today, we will have put four pharmacists through the training between our two pharmacies, costing several thousand euro if one accounts for study time off, cover required, training course fees, etc. Writing this morning, I note the sensible increase in fees for delivering the service that has transpired this year; on the same morning, however, that I get an email asking will we now order the 12 Anapens needed to offer the service.
We have 50 adult vaccines coming to us in total. Yes, in total, between the two pharmacies, after several weeks of emails requesting that we make orders from a website that wasn’t working. We delivered 200-plus vaccines last year, and this eejit was on local radio last week advocating that more people get it, given the Covid situation. We now won’t even have enough to cover the number of new patients who are on our waiting lists at present.
Who knows when we’ll have the kids’ vaccines, and how many we’ll have of those, given the ridiculous cold chain arrangements. No doubt a money-saving exercise by bureaucrats, which ended up in vulnerable and stressed-out patients who needed them last year trawling pharmacies and GPs, and pharmacies and GPs binning thousands of euro worth of vaccine stocks, as pack replacement didn’t allow for ‘just in time’ planning and efficiencies. It is disheartening and frustrating, as well as expensive, to offer the service to patients. Another season coming around, and I’m again asking myself why we haven’t joined those who just refuse to offer the flu vaccination service due to the stress, expense and disruption associated with it.
Extended services through pharmacies, how do! Ten years on, they can’t even do this one properly, so what hope is there for further initiatives until there is a serious reality check on the debacle that is this one? One solution would be to get rid of the bureaucrats in this cold chain mess, speak to the suppliers and pharmacists on the ground, use a tried and trusted and fully-functional supply chain, on pack replacement, and remove the layer of incompetence and complexity that has us all tied-up in knots.
It is the patients and Irish public who are suffering as a result of our energies at the coalface in primary care being given to the wrong thing. I do, however, take some small comfort in the contrarian opinion that an efficient bureaucracy is the last thing that we need. If we were to end up in a situation where we’re being imposed upon to undertake more non-patient-facing, resource-sapping paperwork exercises more efficiently, then we’re well and truly f***ed!