Irish Pharmacist speaks with pharmacist Eamonn Brady about working in care homes during the height of Covid-19

Eamonn Brady owns two pharmacies in Mullingar, having purchased Whelehans Pharmacy, Pearse St, Mullingar, in 2005 and since a major revamp in 2014, he has developed it into a centre of excellence for health and wellbeing across three floors. In addition to core pharmacy services, it also incorporates a beautician, physiotherapist, chiropodist, audiologist, holistic therapy service and counselling service, along with a variety of new on-site specialist clinics.

Business growth is primarily down to the expansion of the business at its Residential Care Fulfilment facility at Clonmore, Mullingar, which since its inception in 2017 has expanded to nationwide prescription delivery. The bulk of the staff within the business are pharmacy technicians who manage and prepare medications for patients, technicians who are supported by prep staff, and delivery drivers, all of whom support of team of pharmacists. Whelehans has grown the in-house workforce from five in 2005, to 40 during that time between both pharmacies.
Trading fully throughout the lockdowns, the pharmacy team supported an extremely high number of aged and vulnerable patients based in residential care settings.

During that time, procedures were put in place to ensure continuity of supply of vital daily medication, whilst ensuring the safety and wellbeing of staff in the process. An online prescription service was introduced very early in 2020 to increase further its range of customer options, with the net result being a 500 per cent increase in home prescription delivery.

The pharmacy was able to secure and offer a full range of PPE, (hand sanitiser, masks, gloves, etc) from February 2020 and was also able to support HSE and residential care facilities with PPE in the early days of the pandemic, when supplies were inconsistent, low, and expensive. Most recently in April 2021, Whelehans won the Best Service Provider in the SFA National Small Business Awards, in no small part due to its investment in robot dispensing technology, namely the Synmed robotic automation used by Whelehans.

This was only the third robot of its type in Ireland and is unique, in that it dispenses individual tablets in pods, rather than simply dispensing boxes of tablets. “Twenty years ago, I worked in Guys and St Thomas Hospital in London as a locum pharmacist and was amazed at their pharmacy robot that cost over £1 million,” said Mr Brady. “It seemed like a pipe-dream for community pharmacies to ever be able to access this technology, but with technology improving and the cost coming down, this pipe-dream has become reality.”

Adapting to Covid

He spoke with Irish Pharmacist (IP) about how he has had to adapt his business and methods of care delivery during Covid-19, including helping to roll-out the flu vaccination programme in care facilities, as well as witnessing the social isolation that resulted from the lockdowns.

“We were finding that people loved going to the pharmacy just to have a chat. For example, an older man came in the other day, a retired bank manager who was complaining that he couldn’t even go to his old bank because they just don’t want to see you in there due to the pandemic,” he said. “Also, a lot of banks and post offices are closing down in small rural towns, so pharmacies are almost the ‘last man standing’ in that regard. The supermarkets are great at what they do, but the staff are under such time constraints that they just don’t have time to talk. Of course, pharmacies are busy too, but it’s part of our role to interact with customers in that personal way.”

In terms of working with care homes, he said: “It’s well documented that the pandemic has caused massive challenges in that area,” he commented. “In the first wave, there were a lot of Covid-19 related deaths, through no fault of the homes themselves. In the initial part of the pandemic, it was a case of really managing supply, because drugs were going out of stock because of the massive demands.

The staff numbers were reduced in these homes as staff were out with Covid-19 or as close contacts, and the staff who were there were literally traumatised; pharmacy teams couldn’t physically go to the nursing homes at that time, but we did what we could for the staff there, for example doing medication reviews and training online.”

Vaccinations

The following wave in early 2021, from a mortality perspective, was “as bad as the first wave in terms of Covid-19-related deaths” he told IP, “but in the nursing homes we deal with, we haven’t seen a single death since early February 2021. Transmission rates have gone down, and in the few cases where nursing home patients have contracted Covid-19 since being vaccinated, none have had any symptoms; ultimately, that’s down to the vaccine — we can see first-hand what a massive success the roll-out has been in these homes and I’m able to physically go back to the nursing homes now to do medicine reviews and audits, staff training and patient counselling.”

Mr Brady also spoke about the role of the pharmacist in administering Covid-19 vaccines, which at time of writing was due to start in May following expressions of interest. “There is going to be a lot of work and administration, especially as we have to maintain our normal pharmacy services at the same time, but pharmacists are generally geared-up,” he said. “Irish pharmacists have been administering flu vaccines for 10 years now and this flu season, pharmacists have administered more flu vaccines than in any other year.

The fact that for the first time in 2020, pharmacists were authorised to administer flu vaccines off-site in the likes of care facilities, workplaces, etc, has helped increase accessibility of the flu vaccine to some patients who may not have received it otherwise. For example, this flu season, my team of pharmacists and I administered approximately one-third of the flu vaccines administered off-site in the likes of nursing homes. The Covid vaccine will be another way pharmacists will improve the health of the nation and help people get back to normality.”

‘Cinderella’ of the health service

He went on to describe pharmacy as the “Cinderella of the health service — we are almost forgotten compared to doctors or nurses, for example, and while I think the HSE has done well in including us in the overall picture in terms of administering Covid vaccines, at the time of this interview [May 2021], pharmacists have not administered a single vaccine yet at their premises.”

In relation to Covid-19 vaccine risks, he added that any reported side-effects have been as expected, for example pain at the site of injection, but he had not yet encountered any serious adverse side-effects from the vaccine, with a small number of people needing to take the next day off work. “Ironically, some of the worse side-effects seem to be in younger people, perhaps because their immune system is stronger and they have a bigger response to it but generally, the side-effects have been minimal to my knowledge.”

Mr Brady welcomed the fact that he can now return to personally visiting nursing homes, as while online medication reviews are important, conducting these reviews on-site is preferable by far. Much has been made of the isolation faced by nursing home residents during Covid-19 and in particular, lack of residents’ access to their family and friends. Mr Brady was asked if he has picked up on any mental health issues among residents as a result.

“Definitely — a lot of these residents have dementia and it’s very challenging for them,” he told IP. “A lot of residents get very stressed, wondering why people aren’t coming to see them, and I have heard of some of them saying, ‘my family doesn’t care about me anymore’. At one stage, families could only communicate with loved ones in nursing homes by phone or through a window and if you have someone who cannot really speak for themselves, you miss out on the benefits of that human interaction. Apart from Covid itself, there are some heartbreaking stories around that isolation, but it’s great that visits are now possible.”

Tackling polypharmacy

Mr Brady was asked about the challenges of polypharmacy in nursing homes, especially in the context of trying to provide care during Covid-19. “The issue of polypharmacy has actually improved significantly over the past 10 years, and pharmacists have had a massive role in that,” he said. “I started to become involved in care homes in Ireland in 2002 and having worked as a pharmacist in England, when I came back to Ireland, I was shocked at the number of sedatives, benzodiazepines and strong sleeping tablets that were being prescribed without review.

Polypharmacy is still an issue and through no fault of the GP, patients can go into nursing homes and change GP, which can present an issue. Sometimes in the Irish health service, the link-up between hospital prescribing and GP prescribing is not perfect. The likes of Sláintecare aims to fix some of these issues in terms of more integrated systems between hospital and primary care, including more integrated IT systems, which of course will create uniquely 21st Century issues in terms of cyber security, which was highlighted by the HSE’s ransomware attack in May. ”

In that context, he cited the role of the pharmacist in managing patients on polypharmacy as vital. “In nursing homes, we do detailed three-monthly medicine reviews, with the nurse and if possible, with the GP and cutting-down the number of medications is a top priority,” he said. “I have seen cases where the person would appear to be quite near the end of their life and because of that, the doctor will take them off all of their medications and suddenly, they bounce back and seem like a completely different person, so people can sometimes certainly be over-medicated.”

HIQA also monitors polypharmacy and use of sedatives and the Authority has strict protocols that would not have been in place 10 years ago, as well as improved guidance for nurses and GPs that also helps to address the problem, he added. Even though pharmacists are becoming more proactive in managing hospital patients’ medications, there is still room for improvement, said Mr Brady.

“One thing that we would like to see, and the IPU is pushing for, is for structured medications reviews rolled-out by pharmacists with a reimbursement format, so that people are actively encouraged to go into the pharmacy and have their medications reviewed, with a follow-up with a GP,” he said. “At the moment, it is too ad-hoc and it is up to the individual pharmacist. Pharmacists have a great relationship with GPs in general, but sometimes, some GPs may feel that there is interference by a pharmacist. But most of the time, GPs are delighted to get the input and advice of a pharmacist and that’s a very important interaction.”

Another major issue in nursing homes is deterioration in dementia patients, in whom dysphagia can be a serious problem, and the pharmacist in these cases is instrumental in changing their medications from tablet form to liquids. There is the challenge of many medicines not being available in liquid or soluble form, meaning that at times, some medicines must be crushed.

Using a multidisciplinary approach, the pharmacist works with the GP, the speech and language therapist and the nurse, to advise on what medicines can be crushed or not crushed. Crushing medicines leads to an unlicensed use of these medicines, as manufacturers do not advise crushing, so the benefits must outweigh the risks before a ‘crush order’ is made, “and that is why the pharmacist expertise is so important,” he said. These cases often also present an opportunity to take the patients off unnecessary medications.

Positives from the pandemic

The advent of Covid-19 has also meant some imposed advances in the ways people work, including pharmacists, and one aspect of this is the introduction of Healthmail. “There have been some positives, and Healthmail is a big one,” said Mr Brady. “Pharmacists have been pushing for that for years. It has come in almost as a temporary measure, but it is working very well and it makes pharmacists’ lives, the GPs’ lives, and patients’ lives so much easier, and it is very secure. This is probably a first step, and it will be improved.

What previously held something like this back is the fact that the HSE has so many stakeholders to deal with, that they were almost looking for perfection, like the cloud-based system in the UK, which does take an awful lot of development,” he continued. “The fact that Covid-19 led the HSE into having to create a quick paperless solution for prescriptions cut-out years of procrastination.

“Sometimes, it takes a crisis to get things done and I do think the IPU sees Healthmail developing into a cloud-based system. In the nursing home sector, for example, we supply medications over a wide area in Ireland. Some doctors were reluctant to post prescriptions because of security concerns, so we were literally sending drivers to collect prescriptions, and now we do not have to do that. In fact, Healthmail has cut down on the number of forged prescriptions because of less access to prescription pads,” he added.

Covid has also deprived many industries, not least pharmacists, with the opportunity to attend face-to-face conferences and network with colleagues as previously, and along with most of his colleagues, Mr Brady is anticipating a return to normal in this regard. “We miss that — there are a lot of people you can catch up with at these events so I can’t wait, along with everybody else.”

Future of pharmacy

In terms of the future for community pharmacy, he outlined his hopes for further broadening of roles and responsibilities in the years ahead post-Covid. “Maybe Covid has helped, but I feel we are seen by the HSE as a more integral part of the health system,” he said. “I do feel that we have the potential to provide more services. The GPs are under pressure, especially now with Covid vaccines, and pharmacists can take some of that pressure off.

We are not looking to ‘take’ anything from GPs; it’s not a ‘turf war’ but there are a number of things we could do,” he told IP. “For example, some prescription medications are quite basic, and pharmacists are well equipped to safely supply them on consultation. Viagra and sumatriptan are good examples of this, but other treatments could also be prescribed by a pharmacist, such as mild steroid creams or antibiotic eye drops, anti-fungal treatments, or simvastatin. People are continually having to go back to their doctor for things we know they need.

“It’s also good that pharmacists will be involved in the Covid vaccinations, albeit a slower start than we had first envisaged, but in the future, pharmacists should be involved more in other vaccinations, including the likes of pneumonia, shingles and children’s vaccines, as the IPU have been campaigning for many years,” he continued. “So, for the future of pharmacy, of course there is more online pharmacy now and some might feel that is a threat to the traditional pharmacy, but online pharmacies make things competitive, and competition is healthy.

However, one of our strengths as pharmacists is in the one-to-one interactions and things can be missed in online pharmacy or video consultations; I do believe that it will come full circle — Internet shopping is here to stay, but especially in healthcare, human face-to-face interaction is important, especially with so much information for people on the Internet, some of which is of course is at best misleading or biased and at worst, fake.

“Also, there could be more joined-up thinking with us and the HSE in terms of screening for conditions like cholesterol, blood pressure or diabetes, all of which pharmacists are perfectly positioned to provide,” said Mr Brady. “But the future is bright. There are challenges, but it’s up to us in the profession to embrace change.”
As for the future of his pharmacy specifically, Mr Brady said:

“We are focusing on the acquisition of new nursing home and residential care clients, which to date has been very much a face-to-face on-site activity — however, with the restrictions Covid presented, this is not a viable and reliable option for the next while. To overcome this, we have decided to create a dedicated section of our website for the Residential Care Business. This will create a visual platform that we can point prospective customers towards and gives us the opportunity to showcase to prospective new clients the very best that we have to offer.”