And I hope we grow out of it, says Áine Mac Grory in response to the new I phased dispensing criteria outlined in the community pharmacy agreement 2025
If you work in community pharmacy long enough, you start recognising patterns.
Not because patients are the same, but because their real, everyday needs often fall into rhythms we know by heart. The patient who pops in three times a week ‘just to check’. The patient who asks the same question twice and apologises each time.
The one who collects their medicines like clockwork. The one who never remembers which tablet is which (‘the small round one! You know, the white one!’).
Fran was one of those patients.
Just standard. The kind of patient you see every single day in community pharmacy. She lived a short walk away and came in regularly: Sometimes to collect medicines, sometimes to ask a question, sometimes because she wasn’t sure whether she’d been in already. She could be sharp, warm, scorpy, grateful, forgetful, and often all within the same week. In other words, Fran encompassed the textbook, everyday patients we build our practice around.
And it’s because she was so typical that her story matters so much.
Fran first appeared with her daughter, over from Geneva, who presented with the soft exhaustion of someone trying to support a parent from thousands of miles away. Fran, in contrast, had the look many pharmacists recognise immediately. Vacant, lost and afraid.
Her husband, Tim, had died two years earlier. I am grateful not to have had the displeasure of ever meeting him. He had controlled every aspect of her life; finances, social connections, decision- making. He left her with less than nothing. No friendships, no confidence, and no clear sense of how to navigate life alone.
This, too, is common and too common it is. An article for another day perhaps.
Back to Fran! Now left and dealing with bereavement, isolation, uncertainty, and the slow erosion of executive function that often follows trauma. It’s not unusual to see widows and widowers struggle in ways they can’t articulate. Fran was no different. Her grief didn’t look like crying; it looked like confusion, hesitation and fear of ‘being a bother’.
Over the months, Fran’s routine changed. She came in more frequently. She repeated questions. She forgot dates. She lost track of doses. She apologised for things she didn’t need to apologise for.
Her GP referred her to geriatric medicine and neurology. There were concerns surrounding cognitive decline — possibly dementia. She was still independent in appearance, but the cracks were widening in ways only those who saw her regularly could spot (or monitor).
Her medication wasn’t the most complex: A blood pressure tablet, aspirin, cholesterol therapy, an antidepressant. But medicines safety is not just about what is taken. It is also about who is taking it, how, and under what circumstances.
Fran could not safely manage a month’s medicines. Not because of the medicines themselves. Because of her.
So we supported her with bi-weekly phased dispensing.
This is often where someone jumps to ask, ‘Could you not have put her medicines in a blister pack?’, to which I answer (sometimes through gritted teeth) that blister packs or Monitored Dosage Systems (MDS) are a tool. Not the tool, not a perfect tool, but a tool. They can help some patients and carers. They can provide structure. They can offer visual aid. But the rationale for same is clearly recognised in reputable sources* as useful in patient specific circumstances. That guidance is clear and it states that the evidence for MDS improving adherence is inconclusive* and interventions should only be used when a specific, identified need exists, chosen based on what best suits the individual patient, not a blanket approach
In other words: Blister packs are one option in a wide toolkit. Useful sometimes, inappropriate in others. In this instance, Fran didn’t have the means to privately fund a blister packing service anyway.
More importantly, and this is the critical point, MDS and phased dispensing are not interchangeable, clinically or contractually.
The Primary Care Reimbursement (PCRS) are and have been clear on the fact that MDS is not reimbursed, it is not considered the same as phased dispensing, and the two serve entirely different functions. Fran did not need MDS.
She needed phased dispensing, because she needed regular oversight, human interaction, and the safety net of being seen by experts who understood her patterns.
Until the announcement of the 2025 Community Pharmacy Agreement (CPA), phased dispensing has long been recognised by the PCRS as clinically justified when requested by a GP, required due to product stability, needed when initiating new therapy safely, or in exceptional circumstances where the patient cannot safely manage their medication regimen.
Fran checked three out of four recognitions and only needed one to be eligible for it. She was vulnerable. She was confused. She was alone. She was exactly the type of patient phased dispensing exists to protect. She had a medical card to cover the additional costs that come out of phased dispensing.
The section of the CPA addressing phased fees is concerning to me.
It restricts phased dispensing payments to a tightly-defined list of specific medicines. If the medicine appears on the list, phased is supported. If not, it isn’t — regardless of who the patient is or what their circumstances may be, particularly their financial circumstances. Fran had a medical card. When we first met, she had no savings, no bank account, no money. Social workers aided in setting up of a post office account, but that did not change her income status.
Context is everything. If mismanaged — aspirin can be dangerous, blood pressure tablets can be dangerous, cholesterol tablets can be dangerous. Fran’s medicines were not ‘high-risk’, according to a list. But Fran herself was.
There is plenty of guidance to support this entirely. It emphasises that medicines support must be: Individualised, person-
More importantly, and this is the critical point, MDS and phased dispensing are not interchangeable, clinically or contractually
centered, based on needs, preferences, and capabilities, not constrained by rigid drug lists. The 2025 Agreement stands in direct contradiction to this.
‘If it’s not on the list, it won’t be funded.’ This is not a clinical approach. It is an administrative one. And patients like Fran will feel the consequences first.
In the final weeks of her life, Fran grew increasingly confused. Some days she was frightened to leave the house. Other days she appeared in the pharmacy twice, forgetting she’d already collected her medicines. We kept a close watch.
We spoke gently. We reassured. We safeguarded. Then, suddenly, she was gone.
A hip fracture. Internal bleeding. Too fast to intervene. Her daughter called in one day having landed the night before from Geneva, heartbroken. She thanked us for our help.
Fran was not an outlier. She was not one of the tiny percentage of ‘exceptionally complex’ patients. She was not a rare clinical scenario.
She was common, everyday, ordinary — the core demographic of community pharmacy.
And she needed phased dispensing not because of the medicines she took, but because of the life she was living. I don’t know how I would have even broached the subject of her paying an additional private dispensing fee. That would have added to the confusion, and there was no point of contact or family member to subsidise. Acquiring the medical card had boxed-off that issue in their minds.
This is why a molecule-based phased dispensing model is dangerous: It erases the most important variable in medicines safety. The patient.
Phased dispensing should never be restricted to a list.
It should be guided by: Cognitive ability, living circumstances, vulnerability, mental health, bereavement, isolation, patterns of confusion, and the pharmacist’s professional assessment.
These factors are what community pharmacists rely on.
These factors are not considered in the phased dispensing element of the CPA. It now limits phased dispensing remuneration to a defined set of high- risk medication classes.**
The Frans remind me why we need to do better.
Better at aligning policy with practice. Better at acknowledging clinical judgement.
Better at recognising that medicines safety starts with the person, not the pill. Better at building agreements that support rather than restrict the care pharmacists are trained to give. Fran deserved that. All our patients do. And her story should never be dismissed as ‘exceptional’. It is, in truth, astonishingly ordinary. Which is precisely why it is so urgent.
*For anyone interested in digging a little deeper the guidance I refer to is:
• NICE guideline. CG76 Medicines adherence: Involving patients in decisions about prescribed medicines and supporting adherence.
• NICE guideline. NG5 Medicines optimisation: The safe and effective
use of medicines to enable the best possible outcomes.
**
• Psychotropics (ATC codes N05 and N06) • Opioids (N02A)
• Codeine (R05DA04)
• Pregabalin and gabapentin (N02BF)
Áine is a Superintendent Pharmacist and pharmacy owner with over 18 years of experience working in community pharmacies across Ireland. In 2014, she earned her Master of Pharmacy (MPharm) degree in the UK. Her career journey has encompassed a variety of roles, including locum, support, and supervising, culminating in her recent transition to pharmacy ownership. She is deeply committed to upholding the integrity and vital role of community pharmacy in Ireland, combining her extensive experience with a passion for patient care and professional excellence.
