The old model of healthcare provision in Ireland is in flux; the powers-that-be are advocating a shift to treatment at ‘the lowest level of complexity’ with GPs being asked to man the front lines in the care of chronic diseases as our hospital services creak at the seams.
As at least 20% of a GP’s daily workload is taken up treating minor health problems, it can be difficult for a doctor to find more time to focus on those patients with complex conditions who really need their input. The solution, according to the Department of Health, is to encourage people to take control of and responsibility for their health through self-referral to the most appropriate primary care team member.
For a number of minor ailments, the first port of call is usually the community pharmacist, who is trained to deal with minor illnesses and already spend a good proportion of his or her time advising on these self-limiting conditions.
Minor health complains are every day aches and ills that generally require little or no medical intervention, such as hay fever, constipation, dyspepsia, minor skin irritations, pain and inflammation, coughs and sore throats. A survey by the Irish Pharmacy Union (IPU) confirmed that almost 60% of people regularly rely on their pharmacist’s advice to solve their minor ailments.
By giving appropriate advice and recommending effective over-the-counter (OTC) products, community pharmacists have an important role to play in diverting minor illnesses from the GP surgery. Pharmacists are also trained to distinguish between minor illness and major disease so they can act as a filter for referral where a GP consultation is needed.
“All community pharmacists, to one degree or another, provide this service to their customers. Every pharmacy has a consultation room in Ireland, some of these consultations require a one-to-one conversation in private and, for other consultations it is just as appropriate to have them at the counter or to one side of the counter. It just depends on the circumstances and on the patient,” says Rory O’Donnell, who runs a busy pharmacy in Derrybeg, Co Donegal. He is also President of the IPU.
Pharmacists in Ireland provide approximately 15 million items of advice on minor health problems each year – a number that is growing annually as more individuals struggle with the cost of attending their GP, particularly for minor illnesses. Now, more than ever, there is considerable scope to develop the current level of professional services delivered by local pharmacists into a more comprehensive and structured service to the community.
Both the IPU and the Pharmaceutical Society of Ireland have long advocated for the introduction of a National Minor Ailments Scheme in community pharmacies, as currently exists in other countries including Scotland and the UK.
A minor ailments scheme works by providing non-prescription medication, where appropriate, to medical cardholders free of charge, without them having to go to their GP for a prescription.
“Under the current system, a medical cardholders with minor complains, such as a cold sore or hay fever, has to make an appointment with their GP and sit around in the waiting room so that their doctor can prescribe Zovirax or an antihistamine. This is time consuming for both the patient and the doctor and is an unnecessary drain on GP resources,” explains Rory. “A more progressive attitude to community health care would see pharmacists providing these medicines with appropriate advice on their use.”
At the IPU National Pharmacy Conference in Galway recently, union officials called on the Minister for Health James Reilly to actively engage with them on establishing a National Minor Ailment Scheme. The Minister was reminded of the IPU survey (2006), which revealed that 86% of medical cardholders are in support of this initiative.
In March this year, the Welsh Government announced plans to introduce a minor ailments service in community pharmacies across Wales. The first services will be in place by March 2013 with phased rollout beginning later that year.
“By visiting pharmacists rather than GPs for minor ailments, patients will not need to make an appointment, but they will still be able to get any necessary medicine without charge. This will free up GP time for dealing with more complex conditions, and may also decrease waiting times for appointments,” remarked Welsh Health Minister Lesley Griffiths.
This endeavour to promote a more appropriate use of GP and community pharmacy skills has proved successful in Scotland and the UK. Under the Scottish system, which was introduced in 2006, patients register voluntarily in a pharmacy of their choice and the patient's GP is informed. This enables individual patient usage to be monitored through the pharmacy. There is a potential patient safety benefit and the risk for abuse of the scheme is removed, since patients can only use one pharmacy.
Payment is on a capitation basis determined by the number of patients registered, plus reimbursement for the cost of medicines supplied.
After just two years in operation, a review of the service found that there were 70,000 consultations per month in Scottish pharmacies that previously would have taken place in GP surgeries, and the average cost of medicines prescribed by pharmacists under the scheme was lower than those prescribed by GPs under the same circumstances.
In the UK, the public has been able to access free NHS treatment at local pharmacies in a large number of Primary Care Trusts for some minor conditions since 2005. Key features of existing minor ailment schemes is that the community pharmacist supplies the medication for a set list of minor ailments from a limited formulary and patients exempt from prescription charges receive these medicines free of charge.
According to research in the UK, this service has proved particularly beneficial in areas of deprivation, since patients in socially disadvantaged areas are more likely to receive OTC medicines on prescription than patients in more affluent areas.
Some members of the medical community have voiced concerns that there may be a real potential for excessive use of medicines where a health professional is both prescriber and dispenser. However, when the ‘Care at the Chemist’ study, conducted by the School of Pharmacy and Pharmaceutical Sciences at the University of Manchester, evaluated a minor ailment service in a deprived area of Merseyside, researchers found its introduction did not lead to an increase in medicine costs.
Rory O’Donnell points out that one of the biggest barriers to setting up a minor ailments service in Ireland is the limit of non-prescription medicines that are available to Irish patients through their pharmacy.
“This is only opening up gradually for us here in Ireland – they’re way ahead in the UK where there is a whole plethora of extra medicines available without prescription for a wide variety of minor medical conditions. The availability of the morning after pill without prescription from pharmacies was a welcome addition but, needless to say, we would welcome and call for a greater extension of switches like that - medicines such as fluconazole for thrush and sumatriptan for migraine.”
But, he says, in terms of the ability of Irish pharmacists to deliver this service, they are absolutely capable and willing.
“I believe that pharmacists have the skills, it’s part of our core competence already but any extra training that may be required would certainly be provided,” he suggests. “Firstly, we would have to agree the parameters of this service, involving all key stakeholders at an early stage - protocols and standard operating procedures for the scheme would need to be developed by a multi-disciplinary working group.
“As well as deciding on the list of formulary drugs, consideration would need to be given to what guidelines and advice should be included in the formulary, such as inclusion and exclusion criteria for treatment with the drug, and when to refer to the GP.
“We’re ready to engage at any time in that discussion. The package would have to be a win-win for everybody: The patient would have greater access to healthcare advice; it would reduce congestion in GP surgeries; the health service would benefit by targeting resources and making savings, and of course, schemes such as this promote the role of the community pharmacist not only as a medicines expert but as professionals who are trained to recognise and treat minor ailments and give healthcare advice.”