Gino Kenny on pharmacy minor ailment scheme and GP capacity

Thanks everybody for their statement today. My first question is in relation to the pharmacy force model in Scotland. When was that implemented? The origin of that really was back in 2006 they had a minor ailment scheme and then it became a little broader in 2020. It is just in 2020 and it is that real symptoms focus. It is more like a triage model. You get the assessment of symptoms, advice, referral and or treatment. In that situation can pharmacists then prescribe certain medications in that environment? Yes. In the Scottish model they use a structure called patient group directions to supply the prescription only products and that is to a certain cohort of patients if they fulfil certain criteria. For example they can give acyclovir to treat shingles, they can give fucinic acid to treat impetigo. There are a number of different specific conditions that are prescription only medicines but are supplied by the pharmacist and functional structure consultation. Is there any circumstances in Ireland at the moment that if somebody just says, is there any medications you can prescribe? At the minute we talked about Schedule 8 with medicinal products controlled supply regulations and that is where there are certain prescription only products that you can supply and or administer. So that is how pharmacists deliver flu, pneumococcal, shingles, COVID vaccines but also administer certain emergency medications. So naloxone if somebody has an overdose and if there is glucon if somebody was having a diabetic crisis. There is also salbutamol if somebody is having an asthma attack. So medicine is in an emergency situation. Pharmacists can and do administer adrenaline if somebody is having an anaphylactic reaction. So you have got that immediate kind of urgent emergency care currently being delivered in the pharmacy setting through that structure. So if somebody presents themselves in that situation you can administer that medication? Pharmacists can and do, yes. Okay, that is interesting. Obviously the minor ailment scheme sounds a brilliant idea. Obviously other jurisdictions have implemented that and it seems to be a bit of a no-brainer. Has there been any kind of resistance from GPs in relation to the possible implementation of such a service? Pharmacists and GPs work very closely together in primary care and they have a very good strong working relationship on a local basis. The idea here is the patient and I think you have got two healthcare professionals who will put their patient first. If the patient can be dealt with at the lowest level of complexity, be that in the pharmacy, I think GPs can be supportive of that and have been. So we will often refer patients to GP. Equally GPs will sometimes refer patients to pharmacy. So I think being able to work together and put the patient as your kind of core element. And if pharmacists are, I think, embedded more into primary care networks, that would become even stronger in terms of that interdisciplinary working in that primary care setting. Okay. In regards to one million appointments, where would you get that figure from? This is not criticism. It is a great idea. Yes. So there was work done back in 2016, 2017, and we can share that report. I do not have the exact detail of all the figures there in terms of how it was worked through, but we can certainly submit that if necessary. But we looked at the number of the types of conditions that were being treated in the GP setting, the types of medications that we know can be utilised to treat minor ailments. We can look at the dispensing data in the state and we can say, well, actually, this is the number of incidents of those particular types of illnesses that are being treated in the GP setting. So actually, if we take that out of their workload, we could free up one million consultations. We worked it out to be something like 100 full-time equivalent hours worth of capacity within that sector just by introducing a service such as this. What would the classic example of that be? Of a minor ailment? Say a person going to the GP and their interaction ending and coming to pharmacists in relation to the minor ailments. What would the classical presentation be if there is a classical presentation? Well, there is a range of different conditions. We have estimated there is something like in Wales they treat 26 conditions, so there is quite a number. But if we take the example we took earlier, like uncomplicated athlete's foot, there is a cream that you can get over the counter. You come into the pharmacist and the pharmacist can assess your symptoms and say, I know you need that medication. Unfortunately, I cannot give it to you because I cannot provide this item free of charge. Even though it is right beside them? Oh, it is beside us on the counter. We could reach back and pick it up, but we cannot because they need the piece of paper that says, the doctor has written the prescription, therefore it is approved on the medical card, therefore the pharmacist can supply it. You can imagine the time and effort is taken for the patient to have to go off. It seems ludicrous. It just seems ludicrous. Yes, we would agree. Why have they not changed it? That is a question I think for the department, but we hope that they will think about it and maybe agree that this is something to do. Something as rudimentary as something like that. Yes. It sounds like it is a ridiculous situation where somebody has to go to a GP. When we talk about care at the lowest level of complexity at all times, this is a clear example of that. If it is not complex, the pharmacist can safely deal with it. They should be unable to facilitate to do so. Obviously there must be resistance somewhere. Obviously this comes from probably different vested interests as such. I don't know. I think change can be difficult. Dermot might speak. Yes. As we mentioned earlier, it is about thinking outside the box. It is about being agile. It is about looking at being disruptive. Ultimately, as Susan and my colleagues have said, it is about patient care. Ultimately, it is about lack of planning. But in fairness to the minister at the meeting, he certainly seemed to be very keen to move forward on some of these proposals. But colleagues who have been president of the IPU before me, Cathy was one a number of years ago, have heard similar words and platitudes. Really, it is about action at this stage. In terms of the minor element, just to give you a little bit more context, it is about equity of access. A person, if they have money in their pocket and they are able to get this particular product, then they can source the product and get it in the pharmacy. Whereas the person with the medical card, they have to recourse back to the GP. That is an inequitable system. But equally, as Susan has mentioned, it is about expanding the scope of practice. There are a number of other conditions that the products would be prescription only currently. It is about thinking big and moving on some of those. As your colleagues have said, working under protocols. Very often, there may be scenarios where we will not be supplying a product. For example, as the other deputy mentioned, emergency contraception. We would often do consultations where a product supply is not suitable and will be referred to the GP. We would see that may still be the case with regard to minor elements. The morning after pill, you do not need a prescription for it, do you? No. Okay. My final question is in relation to contraception. Again, it is ludicrous that the interaction, you would need a prescription. Is there any other states in Europe that are happening, that you would need a prescription for, again, rudimentary medicine such as contraception? Yes, there are some states in Europe where you do need a prescription for contraception, but there are just as many where it is available without prescription as well. We, as Dermot has said, we want to be proactive. Do you know which countries has this kind of still? Prescription only medicine? Yes. I would need to be sure. I can get that information to you. Even our nearest neighbours, the UK, moved in July 2021 to move progesterone only contraceptives to pharmacies supplied. Okay. It would be interesting to see what countries still have this policy in relation to… It may be the kind of historical… I am careful how I say this, but yeah, there might be… Yes, there may… Tomorrow. Yes, yeah, yeah, yeah. Okay, I think I am running out of time. Yes, thanks very much. My final question is in relation to the drug Caraban. I do not know if you are aware of this drug and I know some people have contacted us in relation to this issue and it seems very convoluted that such a drug that has… It is very kind of effective in relation to acute nausea that women have to go via… Correct me if I am wrong on this one. They have to go to their consultant and then they get the prescription via the consultant. They go to the GP and they get it via the GP, but they are not reimbursed immediately. So, obviously, it is making accessibility very, very much more difficult than it should be. I know the Minister has put funding in relation to the accessibility of Caraban, but it seems a very kind of arduous process in relation to women getting this very, very vital drug. I do not know if you would like to comment on that. Yes, I think we would agree with you. It is great that there is funding put forward, but there are structures in place with the PCRS and the HSE in terms of how that actually works in practice. Often, when they bring new medicines to the market in terms of funding them, they will put some specific restrictions on the supply of that, and that is to control spend in often cases. With Caraban, the structure they put in place is, yes, you are right, you have to go to a consultant in the first instance, so the very first prescribing of Caraban needs to be consultant-initiated. After that, the patient can go to the GP and their second and third and subsequent prescriptions can be GP-initiated if necessary. Once the initial approval is in place, then the GP can follow on with that prescribing. The patient can come from the hospital with the consultant approval to the pharmacy if they are a private patient. If they are a medical card patient, you have to do that step where you go to the GP, get it written on the medical card prescription and then come to the pharmacy. There are lots of barriers along the way. There are lots of places where there is a barrier to access. I guess what we would say is we welcome the funding for Caraban, but we think the system is in place to realistically have it approved in practice and women actually accessing it put too many restrictions in place and just delay the access for those women. The Caraban is a non-licensed medicine, is it? If you talk about unlicensed, it is licensed in another country, it is just not licensed in Ireland. For acute nausea? Yes, it is safe and effective, but it does not have the licence in Ireland because the company have decided not to apply for that licence and place it on the market. I presume if it was licensed, then there would not be this issue? Am I correct on that? I do not think you can say that. It all depends on the HSC. The HSC are the ones who make the decisions around how medicines are accessed. We have plenty of licensed medicines in Ireland that have similar type of restrictions in order to control access funding, make use of the drug's budget, but those are the kind of things when we talk about administrative burden in pharmacy, all of those different systems, dispensing a prescription is not quite as simple as it used to be. A lot of your time and attention is focused on the administrative, am I going to get paid for this, where it should be focused on the clinical, is it safe for this patient, does it interact with their other medications? That kind of thing. Thanks very much.