Will reforms in phased dispensing work out for pharmacists and their patients? Niamh Cahill reports
Reforms in phased dispensing will take effect on 1 June after a six-month delay in their implementation following widespread anger from political opposition parties and some patient groups about the removal of free blister packing services for patients.
The new arrangement on phased dispensing under the Community Pharmacy Agreement does not exclude blister packing, but rather introduces a structured medicines optimisation support service.
According to Sinn Fe?in spokesperson for Health David Cullinane, the changes represent a “climbdown” by Minister for Health Jennifer Carroll MacNeill. Mr Cullinane said: “The Community Pharmacy Agreement was originally drafted and approved by the Minister to explicitly exclude any reimbursement of blister packs, despite a known problem that some patients were getting blister packs for free while others were being charged.”
He said the Government was caught out “penny pinching” and that the original proposal was “cruel and wrong”. But while welcoming the amended reforms — following renewed talks with the Irish Pharmacy Union (IPU) — he said they stopped short of a “genuinely universal needs- based system”.
To date, it appears that the new agreement has been met with much less ire than its predecessor. But what will the amendments mean for pharmacists, and will patients be satisfied with how their medication is dispensed?
‘Well received’
According to Duleek-based pharmacist Kathy Maher, the new agreement has been “well received by pharmacists”. The former president of the IPU told the Irish Pharmacist (IP) that pharmacists were happy with the changes and that a webinar held by the IPU on the new agreement had helped to provide understanding and insight.
Importantly, the changes offer pharmacists an opportunity to discuss medication optimisation with patients in a meaningful way, Ms Maher said.
She added that international evidence does not support the widespread use of monitored dosage systems (MDS) such as blister packs to support medication management.
“What the evidence supports mostly is the intervention by pharmacists, having a conversation with patients. I think this new arrangement will facilitate that happening better,” she said.
“There isn’t any evidence to support the use of blister packing and, in some cases, it can be detrimental to patients. What this does is, it takes the ownership back to patients in terms of what their prescription is and what their medicines are for… the pharmacist can recommend something that might be better than blister packing.”
Pharmacists will be able to use their own clinical judgment to provide support and blister packs — unit dose packaging of medication — are to be viewed as a last resort for patients.
“Blister packs will remain a last resort in line with the international evidence due to associated risks, including reduced patient autonomy and potential safety concerns,” the Department of Health stated.
According to the IPU, international evidence states that MDS should be a last resort for patients because of the risks associated with their use, such as the deterioration of medicines removed from their original packaging, for example.
Common practice
But the use of MDS remains a common practice in community pharmacy and it is a system that is preferred by many patients. IP understands, however, that many pharmacies do not encourage or indeed promote blister packing.
A 2015 UK NICE (National Institute for Health and Care Excellence) Quality and Productivity Case document on the appropriate use of MDS stated that such systems should only be used on a “case-by-case basis” and noted that it can take 20-to-30 minutes to prepare and check a single MDS.
Blister packs are just one form of MDS, however, which can also include disposable trays and sealed pod systems.
The new agreement has been largely welcomed within community pharmacy, as it is understood many pharmacists were concerned about people losing access to blister packs due to the removal of phased fees. The amendments follow renewed engagement with Department of Health officials on phased dispensing in recent months after a public backlash to proposed changes in December last year.
In a statement, the IPU said that the agreement would “enable community pharmacies across Ireland to provide enhanced medicines optimisation supports to those with the greatest clinical need”. Outgoing IPU President Tom Murray said: “Pharmacists use their expertise every day to support those managing complex medicines, living with cognitive or physical impairments, or facing significant social challenges. This agreement strengthens our ability to protect vulnerable patients while supporting the safe, effective, and evidence-based use of medicines.”
The IPU said it looks forward to continued engagement with the Department of Health and the HSE on the implementation of the agreement. A formal review of the new arrangement will take place within 18 months.
A Department of Health spokesperson stated that blister packs have never been State-funded. Phased dispensing has been supported for medical card (GMS) patients since 1996, however.
Minister Jennifer Carroll MacNeill has previously said that some pharmacists had inappropriately submitted claims for phased dispensing to the HSE when, in reality, they were using MDS, a practice not agreed with the State.
A Department of Health spokesperson described phased dispensing as medicines supplied in smaller, scheduled amounts (for example, daily or weekly pick-up), usually for high-risk medications like antipsychotics or opioids.
Blister packs, they said, are “pre- organised packs showing what medicines to take and when, typically prepared weekly to support patients who might need help remembering when to take their medicines or those who have complex medication routines”.
The spokesperson stated that the changes were being introduced because the older system linked payment too closely to packaging rather than care
Outcomes
“The new approach focuses on outcomes for GMS patients, not the number of items dispensed or blister packs. The new flexible system is also designed to help pharmacists in their direct patient care role, as it supports professional judgement and reduces administrative burden. The funding provided will support a range of appropriate and practical intervention adherence supports — for example, medication reminder charts, easy-open packaging, large print or braille labels, medication alarms, phased dispensing, and blister packs (where clinically appropriate).
“It is important to remember that the available evidence, and international practice, recommends that blister packs are only used as a last resort because they can negatively impact patient independence.”
Pharmacists have been digesting what the changes will mean for them and the IPU has issued an FAQ document and addendum document explaining the agreement and how it will operate. The documents, seen by IP, outline the introduction of two new fees under the service — a GMS medicines optimisation fee, and an enhanced medicines optimisation support fee.
Regarding the GMS fee, it has been agreed that phased dispensing fees (€20-to-€24 million) will be transformed into a GMS medicines optimisation fee, according to the IPU. This equates to €0.35c per GMS item dispensed. Around €20 million in phased dispensing funding has already been used to support dispensing fee increases under the Community Pharmacy Agreement.
The GMS fee will enable pharmacies to provide whatever medicine optimisation supports they consider “clinically appropriate”, the IPU stated in one of its explanatory documents.
The supports will be provided to GMS patients who, due to the nature of their illness and/or the level of support available to them, need more focused supports to help them manage their medication.
These include patients on high risk medicines and who are at risk of misuse of those medicines; patients with an intellectual disability; maginalised patients, such as the homeless; patients with dementia or a cognitive impairment who have carer support; patients with a physical impairment that impacts their ability to use conventional packaging and who do not have carers, the IPU stated.
Patients in the groups listed above, and GMS patients in receipt of phased dispensing or MDS free of charge in August 2025, should not be charged for these services.
For patients deemed to be outside of these cohorts, supports — including blister packing if required — can be provided on a private or fee- paying basis. The cost of this private service will be set by each individual pharmacy. Where dual eligibility exists — eg, patients on the Long Term Illness (LTI) scheme and GMS — all medicines prescribed under LTI must continue to be dispensed under the LTI.
The IPU warned in its addendum document that “in the event that any anomalous claiming behaviours were to emerge (eg, if pharmacies were to move claims from one scheme to another), this will need to be dealt with at contractor level and the new fee arrangements may be reviewed”.
Support fee
The enhanced medicines optimisation support fee is a monthly patient care fee of €32.50 “for eligible GMS
The operation of changes will be kept under review and an independent research body will be commissioned
patients who require medicines to be supplied at intervals of less than one week and who meet the agreed criteria”, the IPU stated. The criteria includes patients who have been prescribed a medicine of a specified class and prescription directing medicine be supplied daily, or twice weekly, for example. There are around 6,000 GMS patient nationally who have their medication dispensed more than once a week.
In its addendum document, the IPU said: “Repurposing phased payments in this manner would be implemented in a way which includes all the key vulnerable patient cohorts while at the same time removing a significant amount of administrative burden from pharmacies, general practitioners (and indeed the HSE).
“Investing the re-purposed phased payments in this manner also recognises pharmacists’ expertise in medication management and medication safety. It will provide greater flexibility to pharmacists to decide what optimisation supports are most appropriate, where clinically indicated, for medical card patients who meet defined criteria. Empowering the pharmacist to engage with these patients, on such an individualised manner, will ensure that those patients are supported to manage their medicines in an individualised way.”
The operation of changes will be kept under review and an independent research body will be commissioned to carry out “an evidence-based review of pharmacy- delivered medication optimisation processes and systems,” according to the IPU.
The IPU has told pharmacists that the supports available will be reviewed within 18 months to help pharmacists identify appropriate options for their patients and to review the operation of the service. However, detailed arrangements for the review have yet to be confirmed, it said.
