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Doling out more work to pharmacists is fine in theory, but the problem is they’re already struggling with existing demands, writes Fintan Moore

It has frequently been pointed out that community pharmacy is an untapped resource that could help alleviate pressure on the overwhelmed primary care sector. The logic is that there are other functions that pharmacists could take on to improve speed of access for patients and free up valuable time for GPs. Every day pharmacists are already plugging gaps in the system caused by the inability of GP surgeries to cope with the demands they face. Proposed legislative changes to allow us to treat some conditions like conjunctivitis would be helpful all round, as would being able to dispense oral contraceptive pills (OCPs) without a prescription. So what’s the downside?

The problem is that us pharmacists are already struggling with the existing demands on our time, especially the accumulated load of non-clinical distractions on top of our core function which is to dispense medicines safely and accurately. We currently have to check GMS numbers are valid; check that the GP hasn’t accidentally treated a GPV card as a GMS card; collect the GMS levy or listen to the excuse for not paying and make a record of the non-payment for supposed payment at a later date; check that the GP hasn’t prescribed unapproved nutritional supplements, or that the approval is in place if they have; check that a diabetic patient hasn’t exceeded their allowance of test strips; check that a Sildenafil patient hasn’t exceeded his allowance of four tablets a month; check that a benzodiazepine prescription has been properly written; check if a patient getting a nicotine replacement prescription is getting it for the first time and is therefore allowed only two weeks’ supply instead of four; explain to a patient that the GP hasn’t bothered (yet again) to write “do not substitute” beside the brand name; check that a patient is still eligible for phased dispensing; explain to a patient that the dentist has written medication on the DTSS prescription that isn’t covered by the DTSS; process a prescription for a patient that is covered partly by the GMS and partly by the LTI scheme; check that enough months exist between Prolia dispensing dates to avoid non-payment; photocopy and staple invoices for the growing list of ULMs; work through the time-consuming high tech hub to place an order; check that the computer-generated prescription with the wrong strength printed on it for Amlodipine is still a mistake for the 11th month in a row because the GP can’t or won’t amend it on the patient’s record; and so on and so forth.

Ideally, any other new services should also be ones that can be scheduled but I appreciate that this may not be possible

In addition to the bureaucratic and administrative minefield that we tiptoe through we are also required to deal with multiple other random queries from patients during the day. It’s perfectly possible to end up with simultaneous consultation requests for a morning-after-pill, for a codeine product, and for Motilium. These can come in at the exact same time that the pharmacist is already trying to make sense of a 10-item hospital prescription with multiple changes, errors, and omissions from the patient’s pre-admission medication. So I’m really wary of any new roles that stretch even thinner a pharmacist’s ability to cover everything. In contrast, the beauty of pharmacists offering vaccination services is that they can be done by appointment at a time to suit the available number of staff. Ideally, any other new services should also be ones that can be scheduled but I appreciate that this may not be possible.

Stripped of reason

We all know that the HSE likes to have rules about what items it will or won’t pay for. It also has rules that require some items to be approved for specific patients before payment. There are a few oddities that crop up – for example, Entresto is not automatically allowed on the LTI scheme for diabetic patients but it will always be approved if a request is made for patient-specific approval. This begs the question of why not just add it to the core list for diabetes, but that would be too simple.  Similarly, I’ve never heard of approval being denied for any oral nutritional supplements. Given that the HSE is paying staff to operate its approvals process – but never seems to refuse any applications – the extra administrative expense of the process is possibly costing the HSE more than it actually saves.

I recently fell foul of the requirement for pregnant GMS patients to be pre-approved for extra diabetic strips before the Primary Care Reimbursement Service (PCRS) will pay for them. I had dispensed extra strips for two months before realising she wasn’t approved, and the claims for payment were rejected. The patient is now approved so it would seem only fair and reasonable that I should be able to send a reclaim for the unpaid strips seeing as she was actually pregnant at the time of dispensing and had a genuine patient need. However, the rules in this case are the rules, so the PCRS is refusing to reimburse me. Go figure!

Not always right

One thing you learn quickly in community pharmacy is that the customer is not always right, and that they can also be a right pain in the backside when they’re wrong. We had a woman in recently wanting to pick up a month’s supply of her mother’s medication.  On checking the patient file we had a record of the medication having been dispensed a week before. Among the items on the prescription were Tylex and Diazepam, so we politely queried the request with the woman. She went off at the deep end, swearing blind that she hadn’t collected anything, absolute adamant that her mother was out of medication, and rudely and loudly complaining to everyone in the shop about it. To buy time to figure out what had happened we asked her to head home while we checked the situation. She left with ill grace, then rang after a while to say that her mother had the bag of medication. She made a half-assed apology, which sadly won’t undo the damage caused to our reputation in the eyes of the other people who were in the pharmacy when she was criticising us.

Fintan Moore graduated as a pharmacist in 1990 from TCD and currently runs a pharmacy in Clondalkin. His email address is: greenparkpharmacy