Terry Maguire on what needs to happen for the plans in the Expert Task Force report to be implemented, and the urgent need for pharmacist prescribing in the Republic
Our erudite Editor, who monthly commissions, collates and curates the excellent content that is this magazine, penned an excellent piece himself for the May edition, titled ‘Unchartered Territory for Irish Pharmacists’. This was a presentation of views, concerns and opinions on the Expert Task Force to Support the Expansion of the Role of Pharmacy: Final Report. I don’t know who within Irish Government circles chooses commissioned report titles, but this is a title so banal that the report, by dint of its title, is destined to remain on a shelf, gathering dust, unread. Which is a great pity indeed, as its content is so important not only to Irish pharmacy, but to healthcare in Ireland and the population it serves. But before I come over all President Higgins, this report is perhaps 40 years, certainly 20 years, late. That maybe is harsh and unfair. I accept that in 2008, the PSI published a report on the future of pharmacy, but little has been said or action taken since. For the State to leave Irish pharmacies in the 1960s, with development largely controlled by market forces, is a failure and a shame. This report, if read and actioned, will allow access to the huge potential efficiencies from a properly-developed pharmacy network and workforce. This vision for the profession started in the UK in the 1970s, and where it has been slow and patchy, we are getting there. Simply paying your pharmacies to supply medicines is criminally inefficient. Ireland needs urgently to move to pharmacist prescribing.
Concerns
Our Editor reported mainly on the views of two sectors; the medical profession — the Irish Medical Organisation (IMO) — and pharmacy contractors — the IPU. Unsurprisingly, the IMO is polite and claims support, but… Note to Editor: Where a supportive clause in a sentence is followed by the word ‘but’, the supportive clause is bullsh**. The IMO has a vested interest to oppose these developments. It claims that a shift of tasks to pharmacists is not supported by the evidence. It specifically cites pharmacybased contraception services, yet there are myriad studies from the UK and beyond that endorse the positive role community pharmacy has, in particular in identifying and referring STIs. Other areas have been researched, all with a positive evidence base, and are referenced in the Final Report. The bibliography covers nearly 20 of its 100 pages, so there is a lot of evidence out there. The IMO is concerned about continuity of care but this, in a modern healthcare system, is merely an IT challenge. The patient must have easy access to all parts of the State’s health services and own a patient record that can be updated by each healthcare professional they encounter and who provides them with care. In N Ireland, pharmacies have access to the Electronic Care Record, so we can assess patient information when prescribing for common conditions. The right to update these records is the next stage. Pharmacists, North and South, have been prescribing for common ailments over-the-counter for 150 years and doing a pretty good job, going by the evidence. A common ailment service will free-up and open additional access for patients, and these areas of treatment need to be extensive and ambitious. In the North, we now prescribe antibiotics in our Pharmacy First services for UTI and sore throat using simple desktop tests to establish if bacteria are present. The evidence base shows that pharmacists are less likely to prescribe antibiotics than GPs, something the IMO fails to acknowledge. We use two regulatory tools to support pharmacist prescribing; Patient Group Directions (PGDs), and Independent Prescribing (IP). All registered pharmacists can use PGDs; protocols for the specific use of a POM medicine for a defined condition such as UTI in a certain cohort of patients. Independent prescribers, those pharmacists who have completed an accredited course and have an annotation against their names on the Pharmaceutical Register, can prescribe any medicine when working, for example, in a GP practice or in a hospital, and they do so. This is now happening in community practice in the Pharmacy First services. All newly UK-qualified pharmacists from next year (2026) will have an IP annotation on registration. For the old folk like myself, there are IP courses paid for by DoH. At my stage of career, however, I am unlikely to become an IP. Yet this might be risky; as IP pharmacists become more numerous, the use of PDGs in service delivery will be reduced. Pharmacist prescribing was brought into the UK by the Crown Review in 1999 to great fanfare and excitement. The training of pharmacists happened rather quickly, but the DoH failed to provide the necessary services for pharmacists to apply these skills. This must not happen in Ireland. When pharmacists gain prescribing rights, there needs to be a proper set of services to deliver, otherwise the skills will atrophy and the opportunities will be lost.
Education and research
The Report underlines the need for a good evidence base and the educational support to deliver this vision. ROI has the excellent IIOP to ensure the necessary competence is created among the workforce through targeted education programmes. We have a regional service development committee that is currently setting up pilot services. Shingles and common cough services are being assessed and if they provide positive outcomes, will be rolled out, as were the EHC, UTI, and Sore Throat Services after successful pilots. GPs are actively referring into these services, so they don’t perceive the same threat as the IMO. The services are properly commissioned, include a training element, a service specification, and come with acceptable levels of fees. Northern Pharmacies Limited Trust is a charity that funds innovative pharmacy practice research in N Ireland and is currently supporting a number of projects that will innovate the community pharmacy offering that hopefully will become commissioned services that involve pharmacy prescribing. Education and research are essential elements to determine the success of this strategy and they rightly are dealt with in detail within the document.
Workforce
IPU is concerned, as is its raison d’etre, about the workforce aspects and this ultimately comes down to money. This is certainly important, but the IPU should resist the urge to pull down these developments simply as a means of leverage on the Government. This has been a failing in the UK.
What we do
Not wishing to patronise, but as we are a few years ahead in this strategy, I thought it might be informative to describe how my day is as we implement our pharmacy prescribing plan. We are a small pharmacy, and a typical day last week was Tuesday. In addition to the team dispensing over 350 prescription medicines and making up 25 ‘Dailys’ and 100 OTC counter sales, we had six needle and syringe exchanges, supervised 19 methadone patients, and prescribed two emergency contraception pills (organised ‘the pill’ for two teenagers with follow-up to their GP). We had one patient with severe sore throat referred by her GP and who was positive on testing for Strep A. I prescribed penicillin for her without the need for her to return to the GP. We had two urine samples, also referred from GPs; one was positive on testing, the other negative. Antibiotics are only supplied by the pharmacy through PDG on positive tests. We had three follow-ups on our smoking cessation service and supplied nicotine replacement therapy. I supervised five Pharmacy First common aliments supplies, which all involved supply of a medicine. There also needs to be an improvement in IT as part of this development. Since Covid in 2020, all pharmacies collect prescriptions from local GPs. For us, these arrive midmorning. Medicine labels are produced, medicines assembled, labelled and checked before bagging and racking for patient collection. Scripts are submitted twice monthly for payment. Dispensing remains the central activity in all pharmacies, yet it could be so much more efficient. Electronic Transfer of Prescriptions (ETP) has been in place in England for 10 years. We won’t have ETP in N Ireland until 2032! If I had EPT, I would not need a driver to collect from the GP and I would have more time to provide other services. EPT would allow me to draw down the prescription on request of the patient/GP, my computer would help with clinical checks, and then my scanner would check the correct item is supplied. I would then electronically submit the dispensed prescription for payment. The paper prescription would disappear. I could then concentrate more on providing services, which might include taking more care of patients with long-term conditions, but I would really struggle to do this at present.
Pharmacy triage
There must be better referral options for pharmacists if this is to work for patients. When I triage a patient, I should, if I need to, refer them on and be able to target my referral into the wider health service with appropriate urgency. At the moment, I can only encourage self-referral to the GP, and this just does not work. Expansion of the Role of Pharmacy is an important and groundbreaking strategic document that has the power to radically improve the offer community pharmacy has in maintaining the health of the Nation. It does not consider our role in public health, but that is for another day and another discussion. It will be up to IPU to ensure it lobbies for the correct funding to realise this vision, it will be up to the Irish Schools of Pharmacy to ensure that practice research can measure the outcomes, and it will be up to each pharmacist to actively support implement it, as it will assure the sustainability of a pharmacy network into the future and keep our erudite Editor in a worthwhile job.
