2008 Articles

Here is 2008.

January 2008

Fair play, Mary, fair play!

One of the problems of writing a column like this is that any number of things can happen between writing and publication. All the more so when you are dealing with negotiations with the HSE. Here things can change on an hour to hour basis never mind day to day. Added to the mix is that I for one can put very little faith in anything the HSE says. We’ve all seen their spam mail telling us how wonderful they are and how we should be delighted to give them our souls and first born. As I write I have three letters from them in front of me using phrases like “Please accept my apologies for any inconvenience caused,” and “I would like to take this opportunity, on behalf of the PCRS, to wish you, your staff and family, a very happy Christmas and aprosperous (my emphasis) New Year, and thank you for your co-operation with us throughout the year”. This from a body who’s policies would make my and many other pharmacies un-viable when they implement the 8.2% cuts. Some inconvenience! Some prosperity!

Now I’ve always been a bit of a gambler. Nothing major, a few Euro on a match or a race just to make it more interesting. It’s the sprinkles on the ice cream as Homer explained to Lisa. So I thought that I might open a bit of a book on who would be the first pharmacist to go bust because of the HSE cuts. A bit macabre but interesting none the less. But this presented an ethical dilemma. What odds should I give on myself?

A little bit of history here. In 1996 I along with others objected to the regulations limiting openings of new pharmacies. I felt at the time that it was unfair to employee pharmacists looking to open their own pharmacy. I didn’t have any ambitions to open my own pharmacy then. Roll on to January 2002 and Mary Harney agrees with my view of the 1996 regulations, albeit for different reasons. Politics indeed makes for strange bed fellows. She wanted more competition in the retail pharmacy market. And she was instrumental in getting the then Minister for Health, Michael Martin to revoke the 1996 regulations. And boy did new pharmacies open, approximately 250 in the next 5 years. Nearly one a week. March 31st 2003 was my week. My nearly mortgage free home was re-mortgaged and a stonking big loan from the bank. I’m in the same boat as many others.

Move the clock forward to 2007 and Mary invokes a ladies privilege and changes her mind. The HSE would now like to see 600 pharmacies close. We have too many they say. But which 600? Let the market decide, after all she wants Boston not Berlin. 3 out of every 7 pharmacies to close, that’s a lot of unemployment. It will never make the head lines as it will be a few here and a few there. When the September 17th cuts were announced SWMBO* said that this would affect the smaller pharmacies less. What cloud in cloud cuckoo land was she on? The larger pharmacies and the chains have much more scope to make cuts adjustments. They also get bigger discounts, and good luck to them. I don’t even want a level playing pitch. The big boys will always have the best of terms.

All I want is a fair set of rules. When two teams meet they know what game they are playing and what set of rules to follow. It is as if we set up to play tennis initially and now the HSE have decided that we will now play rugby instead. To continue the analogy I am on my own and I am facing fifteen prop forwards . And pretty ugly they are too. The business plan that I use when talking to the banks is now meaningless. How are we supposed to plan for our business when the ground rules are being changed on a whim. No consultation, no talks, Big Brother knows best. But as many pharmacists knew and as many others are now discovering Big Brother HSE doesn’t know best. With the old Health Boards we had up to eleven different ways of doing things. Now the HSE says “It’s our way or the highway!” While I thought that Frank Sinatra did a good version of “My Way” I’m not so sure about the Mary Harney and Brendan Drumm’s version. I’m sure that they are intelligent people who know many valuable things, but they know sod all about community pharmacy. So they paid for and got Indecon’s advice. And then promptly ignored it. If Indecon had supported them in what they were doing they would not be shy in spinning this to the media. No, Indecon specifically advised against the way they were going so they did their best to bury it. At least part of the Indecon report raised a few chuckles on my face. The version released had “commercially sensitive” details blacked out. Indeed whole pages were blacked out. What commercial secrets demanded such protection. Details such as the number of Unicare and Boots pharmacies in the country. Maybe they should have tried to ban the phone book at the same time. On page ii of the executive summary the number of pharmacies per warehouse is blacked out. However on page 36 a single digit is blacked out as the number of pharmacies per warehouse followed by “Only Scandinavian countries…..exhibit denser warehouse figures”. On page 37 we see that Sweden and Finland are at six, Norway is at seven and Denmark is at nine. No mention is made of Switzerland at ten so this leaves Ireland’s single digit blacked out figure as eight or nine. Another of the reference sources is blacked out but the blacked out part is immediately followed by “Irish Independent 19 May 2003” This so secret that it was published in a daily newspaper but we are not supposed to know about this.

At eight or nine it would mean that there are somewhere between 155 and 175 pharmaceutical warehouses in Ireland! About six for every county. It looks like they have counted every pharmaceutical company that has a pack of paracetamol in their first aid box as a warehouse. All this would be farcical except these are the people that are charged with running our health service.

We are not looking for much. We know you want a new contract so sit down and we can discuss it in an adult fashion. So you cannot talk money because of the Competition Act. The appoint a truly independent regulator who can set the prices.  At the risk of sounding like a masochist Mary, all I want is a fair crack of the whip!

*She who must be obeyed.

Febuary

What future, the Methadone scheme?

The recent bit of a to do over the Methadone Scheme got me thinking about the future of the scheme. When the scheme started back in 1996 it was full of lofty ideals. It was to have the patients see doctors in their local community and get their methadone in local pharmacies. All part of a big rehabilitation. They were to get counselling to deal with their addiction problems and then to be weaned off the methadone. The scheme got off to a rocky enough start. This was mostly due to a number of unstable patients who were probably not really ready for community treatment. But this was due to the pressure of numbers attending the clinics. They had to get them out some how.

There was no doubt that the clinics were bulging at the seams and that the Health Board was unable to manage. Community pharmacy got the Health Boards out of a hole but were quickly taken for granted. Not much has changed it seems.

The brave few pioneers, and it was a few to begin, took it upon themselves to meet a need in their communities. As the scheme expanded though there seemed to very few coming off methadone. Yes there was a turnover of clients at each pharmacy but few enough on a reducing dose of methadone.

Now as the scheme has matured there seems to me to be a large number who are becoming a permanent feature on the scheme. Why are they on methadone so long I wondered? So last October, I took some extra time with my methadone clients to ensure they were aware of the alternative arrangements, and to hear about how they felt about the methadone scheme. For me at least the results were a bit of an eye opener.

To start I explained to them my reasons for withdrawing from the scheme. I told them that the HSE were messing me around. (Actually I used slightly stronger language, when in Rome etc). The HSE won’t talk to my representatives and wouldn’t deliver on what they had already promised. Nothing new there. Not too surprisingly they could relate to being messed around by the HSE. Their attitude was “Fair play to you, they mess you around, so stand up up them”. When I told them that the HSE’s alternate location was the clinic in the Glen Abbey Centre on Belgard Road the universal answer was “Where’s dat?” Followed by asking what bus goes there, as despite the celtic tiger most have to rely on public transport. I then asked them about their experiences and opinions on the scheme and if they ever considered coming off methadone.

Did they ever want to come off methadone?

This is where the answers surprised me most. I was expecting it when a good number of them said that they had been on methadone over 10 years. One was on it nearly 20 years. Most of them did and some had tried with minimal success in the past. This question produced the most varied answers. One told me that she wanted to come off it but she reckons that if she did that “I’ll be back on the gear in three months”. Another was more pragmatic. “My probation officer said that I would get a lighter sentence if I said that I was on methadone” (He was wrong.) The dreamer said that if he ever won the lotto he would book himself into “One of those private clinics and get meself clean”.

Then thinking about it I realised that in the 10 years that I have been involved with the methadone scheme in three different pharmacies I had only ever seen two clients come off methadone. One had been re-started on methadone after several years clean, built up to a dose of 50ml daily. Then after a year and a half back on methadone started a reducing dose. Over nine months she got herself down to 3ml daily after which she stopped altogether. The other was a lad who with family support got a place in a long term residential course. One of the conditions was that he had to take no drugs while there. He happily went from 30ml daily to zero over a few days so he could take his place there. Another chap having finished college and started in a good job decided that he would like to come off. He went from 55ml to 50ml to 45ml over two months. He found that 45ml wasn’t enough so he is now back on 50ml. I’ve little doubt that given time and support he will get himself off methadone.

For many of the others the dose seems to be rising. In many cases this increase is a response to some crisis or as a deal in return for staying off some other substance. When the scheme started 80ml daily was considered the top dose which was only rarely exceeded. At present half of my clients are on bigger doses than that. Where is it going?

A final question that I asked them after one week attending the Glen Abbey Centre was which did they prefer, the clinics, G.P.s or pharmacies? No prizes for guessing the answer. Although one answer did catch me off guard. While she preferred collecting the methadone in the pharmacy she preferred seeing a doctor in the clinic. The clinic itself she hated, describing it as walking through a drugs supermarket full of people she would prefer to avoid. “But” she said, “at least you got to talk to a counsellor every week.” I quizzed her on this, do they not offer any counselling when she sees her G.P. every week? “No, all they do is check your urine and give you a prescription.” The brother of another client asked his doctor if they would consider reducing his dose and getting him off methadone. “No” he was told, “you’re like a diabetic who needs insulin every day for life, you’ll be on methadone for ever.”

So as I asked in the title, what future the Methadone Scheme? Certainly the approach seems to be to get the addicts away from needing crime to fund their habit. And those of us who can remember the eighties and nineties can vouch for it’s success there. But what of the methadone clients themselves? What is their future? A lifetime of going to their G.P. every week, give a sample and then go and collect their methadone? The G.P. services being offered to methadone clients seems to be a mixed bag. From a pharmacists point of view, the way things are going the methadone scheme will put my kids through college.

March

This was edited slightly, so this is not exactly as it appeared in March Irish Pharmacist magazine

Thank you, Prof Dum Dum.

To start off, I would like to give thanks where thanks is due. Pharmacists by our nature tend to be professionally isolated. Standing, physically present in our dispensaries up to 60 hours per week, we get little enough chance to meet with our fellow pharmacists. Now however thanks to Prof Dum Dum and his cohorts I have been meeting with my fellow pharmacists on a weekly basis. As well as those I already knew I have got to meet and get to know many more of my peers than I would have ever if I had been left to my own devices. I find this to be empowering and for that I thank you Prof Dum Dum. This has also re-politicised me and for this my long suffering wife and family do not thank you!

In some quarters it is held that a little mortification and self-flagellation is good for the soul. While I don’t necessarily hold to this the HSE seems to have taken a new twist on this. “We’ll flay the skin off your back and you’ll be grateful for it.” In an earlier article I wrote how they wanted us to entrust them with our souls and first born. Now they want the skin off our back.

HSE essentially saying “trust us, we will give you a fair fee.” They will set the prices and decide how much you are to be paid regardless of how much you have to pay your wholesaler for an item or how much it costs to operate your pharmacy. If you don’t like it then tough we can just terminate your contact at three months notice. I was detailing all this to a friend who had just returned to Ireland after a prolonged period in Africa. His reaction was, “that’s exactly what Mugabe is doing in Zimbabwe.”

I have a wry smile for the irony that a head of the HSE appointed by the white knights of the free market economy, the P.D.s, is trying to set up a command economy, we set the price, we tell you what you can do. The last time that this was tried was back in the eastern Europe of old. It didn’t work then and it won’t work now.

Now being in business I have no problem with the notion that a business should make a profit. I take an income from the profits and pay my taxes. My (and many others) taxes fund the government and they provide for the nation. Last I heard this was called the economy. If my patients don’t like the service that I provide then they can choose to take their prescriptions and custom elsewhere. As my patients can choose their pharmacy I can choose my suppliers. We sit down, maybe over coffee, discuss terms, agree a price. Over the years I have built up relationships with my suppliers and patients. If something needs to change we discuss it and come to an agreement. This is called the free market. The HSE doesn’t seem to think that this works. At least no to their way of thinking.

As I pondered the HSE’s way of doing business and dealing with pharmacists it occurs to me that Prof Dum Dum might be a closet communist. As with the old communist states only trade unions that toe the state line are tolerated, little more than lackeys. Not much hope for the I.P.U. there. At regular intervals some of the minor minions would produce a press release which came from the creative writing department. Then the state media would slavishly regurgitate this without using any of their critical faculties. Some things never change. I wonder if the HSE has any creative writers on their payroll at the moment. The job description would probably read something like

Has to be able to take lies and use them to write complete and utter rubbish and make it sound feasible. Conscience, morals and a set of ethics may preclude candidates.”

Now I can see how the HSE could have difficulties conducting 1500 or so sets of negotiations with pharmacy owners. Let’s not forget the smoke and mirrors argument about the Competition Act. Wouldn’t it be so much easier if there was just one body that they could discuss these things with?

No wait, surprise, surprise, such a body exists. Can you guess who they are? And even S.W.M.B.O. Mary Harney has done her bit by announcing that there is to be an independent body which will set renumeration rates for healthcare professionals. Like a breath of fresh air the smoke clears and the Competition Act mirror is broken. And still the HSE rush headlong with their new interim contract. They are obviously trying to pre-empt the independent commission. One wonders what they have to fear from an independent commission. Maybe, heaven forbid, it might be truly independent. Maybe it might be unwilling to rubber stamp what ever the HSE wants. Might there be a few flaws in HSE’s arguments? Have they not got enough confidence in themselves? Maybe they didn’t get enough hugs when they were a baby. Or maybe it might just say something they don’t want to hear. For they already have previous form when an expert body produces a report thast is paid for by the HSE. It told them something that they didn’t want to hear. The HSE tried to bury the Indecon Report when it said that there should be no pre-emptive changes and that there should be consultation with all parties.

It may be some consolation to Joe Higgins on losing his Dáil seat that there is an old style communist running the HSE.

When consultants mock and pharmacists jeer

He’ll keep the red flag flying here.”

Nothing is this article should be used to imply that Professor Brendan Drumm of the HSE is in fact a communist. I merely sought to compare the actions of the HSE to those of totalitarian regimes such as Erich Honecker and Nicolae Ceau?escu. However like a clumsy cowboy the HSE has shot it self in the foot. And here’s how.

If they had negotiated a new pharmacy contract with the IPU, chances are that most pharmacists would have accepted what ever the HSE and the IPU agreed. Maybe a bit of grumbling here and there but by and large it would have gone through. But by forcing us to go to law to get the current contract paid they have made us all aware of the terms of our current contract. A the mob chants in Monthy Pythons Life of Brian, “We are all individuals, we are all different”. So now when the independent body comes up with an economic fee 1500 pharmacists will sit down and do their figures. They will all have to decide which deal is better for their pharmacy. The High Court has already decided that the HSE cannot unilaterally change the terms of our contract. So of the HSE want me to accept a new contract then I will have to look and see what is in it for me. While I support most of what the IPU does on my behalf and have appointed them as my representatives in my dealings with the HSE, at the end of the day I will decided if Jordan’s Pharmacy Ltd is going to accept any new deal. And 1500 other pharmacists will have to make a similar decision.

After watching the HSE’s performance in front of the Oirechtas committee last week I have one comment and one question. Who let them out with a gun and live ammunition and get the first aid box ready for their next performance.

April

Who’s afraid of the big bad wolf

I decided when I sat down to write this that I wasn’t going to write about the HSE. There was two reasons for this. Firstly dead lines mean that much can change before it is published. Secondly I reckon that many pharmacists are getting sick and tired of hearing about the HSE. Every statement and action is parsed and analysed to the most minute detail. It will only be a matter of time before the colour of Professor Dum Dums tie becomes a matter for debate and analysis. Red is a return to communism, yellow shows cowardise, green shows republician tendencies and pink we’ll leave to your imagination.

However at the moment the HSE dominates our lives, so here I go again. I set myself a goal. I wanted to see if I could write anything which would help pharmacists in this hour of need. Nothing overly dramatic. There is not going to be a superman or ninja turtle like attack on the HSE. No, pharmacists, we’re a self reliant lot. I am going to give you ways of helping yourself.

The two biggest issues that we have to deal with on an intra-personal level are dealing with stress and anger management. So I thought what interesting ways can I come up with that are particularly useful to pharmacists.

Now we all have our favourite relaxation techniques. My preferred method is to get all my gear on and burn up some fossil fuels on my motor bike around the back roads of Leinster. So if you ever see a blue motor bike and the rider has a mortar and pestle on his back then you can give me a friendly nod. The you can “GET OUT OF THE FECKIN’ WAY SLOW COACH!” However this method of relaxation is a bit inconvenient if you are providing cover for a pharmacy for nearly sixty hours a week. So one of the new age methods that I have heard of involves taking your mind to a “Happy Place”. I have used this method before. I cannot write about my prefered happy place as that it would mean giving this article an over eighteen’s rating. Except to say that it involves some tutus, Prof. Dum Dum, Mary Harney and loads of whipped cream. The family friendly version of my happy place is a little more mundane.

I am in my pharmacy with loads of support staff. I am reviewing patient histories and telephoning doctors with suggested improvements. I am conducting health screenings and getting respect for all of my work and the added benefits that I bring to the patient. And most importantly I am getting paid for all this. I realise that a lot of this is still a pipe dream but I can dream on none the less.

The next part of my self help lesson is dealing with anger management. It is impossible to think clearly about a problem when your brain is clouded by negative angry thoughts. There are two schools of thought in how to deal with the anger. The first involves taking out our anger on some physical object which represents the subject or cause of our anger. I find this method costly in terms of pillows and cushions destroyed. (Maybe I might have a bit too much anger in me.) You could also try sticking pins in a voodoo doll representation of the object of your anger. I have a personal preference for sticking pins in the kidneys or liver region rather than the heart. However you may have to deal with a guilty conscience if the object of your malice does fall ill a disease of your preferred target organ.

The less violent method involves making the object of your anger the subject of ridicule. This is where the big bad wolf come in. I see Prof. Dum Dum as the big bad wolf and SWMBO Harney as little Red Riding Hood. Now the thought of Mary Harney in a Red Riding Hood outfit may induce some strange feelings so just think tutu and whipped cream instead. I now challenge you to think of SWMBO Harney and not smile.

And the big bad wolf. He stalks arouind the town, hiding out in the deep forest making many threatening noises. But as in all fairy tales the villain is a bully and a coward. The good folk fear him when up against him alone. But when they unite and get their pitch forks out he runs for the hills or he ends up as a kebab.

I learned of another technique once while on one of those management courses so beloved of certain corporations. It is for when you are in an interview or negotiations and you feel intimidated by those on the other side of the table. You close your eyes for a moment. Then you visualise your opponents instead of sitting on chairs at desks, you imagine them sitting on a toilet in a string vest and saggy underpants. I thought that I might recommend this to the IPU to help with their next meeting with the HSE. So in the interests of experimentation I tried to imagine Prof. Dum Dum and SWMBO Harney in this pose. Suffice to say my therapist says that I should recover in time with the help of some Prozac smoothies. Next time I’ll stick to tutus and whipped cream.

I hope that this lesson in self help techniques has taken your mind of the mess that is the HSE for a few minutes. I fear however that you may never think of Prof. Dum Dum and SWMBO Harney again without conjuring up images of tutus, whipped cream and little Red Riding Hood. Just remember that there is light at the end of the tunnel. Unfortunately it could also be the head light of the on coming train.

May

He was pacing up and down outside the local community centre for nearly half an hour now. “I better go in now” he thought to himself. He quietly crept into the dingy hall trying to make himself as inconspicuous as possible. The chairs were arranged in a loose circle, no skulking at the back here. There were already a few familiar faces here. He sat down staring fixedly at a spot between his feet. He rubbed the nicotine patch on his arm under his jacket. “Damm this smoking ban” he murmured to himself.

Then after a while one of the older hands let out a polite cough. “I suppose we better get started. Who wants to go first?” There was no rush of volunteers. “How about yourself?” he said looking at Brendan (*not his real name of course). “You’ve been here a few times before, you know the drill.”

“I don’t know where to start.” Brendan blurted out, thinking to himself, “why me?”

“Just start at the beginning and take it from there.”

“OK” he said still staring at a spot on the floor in the middle of the circle. “My name is Brendan and I’m a pharmacist.”

“Welcome Brendan” the room echoed back at him.

“I suppose it all started when I was young. All I wanted to do was to help people. It seemed innocent enough when I joined the boy scouts. We went around doing good deeds and people thanked us for it. Bob-a-job week was such a rush. Doing good deeds and getting paid for it. But I suppose you have to leave boyhood things behind and move on. I decided that I would like to study pharmacy after being inspired by my local chemist as we were called in those days. She was admired in the community, always helping the public get the best from their medicines and helping them negotiate their way around the maze that was healthcare in those days. Never looking for extra payment, just getting on with it. She was one of the lucky ones. She sold out to one of those foreign chains a few years ago and is now enjoying her retirement. Good luck to her. So off I went to Dublin and to tell then truth the next four years are a bit of a blur. I got caught up in the whirl of college life. Doing things that I thought were important then. Ten thousand words on pharmaceutical care for patients with renal insufficiency. Does anybody pay attention to that stuff now?

Then I settled into my pre-reg year. I thought I knew it all! I’d sort out pharmaceutical care for all of my tutor’s patients. Boy did I get a rough landing! Not from my tutor, he encouraged me to help them all I could. GPs who wouldn’t listen, they knew best, hospital docs who couldn’t be contacted even if you could decipher their signature and a health board structure that makes Pans labyrinth look like a simple cross roads. Not to be deterred I struggled on. Monitored dosage packs and weekly dispensing for those who couldn’t manage. Sourcing un-licensed medicines for those poor sods whose disease didn’t respond to the standard licensed treatments. Never a hint of extra payment for these time-consuming services, but I was happy just to help people out. I didn’t want much then nor still don’t now. Raise my family, pay off my loans and put a bit by for my retirement. Not much to ask.

And now we’re the pariahs in society. Nobody will talk to us. We’re responsible for all of the countries ills. The down turn in the economy, we’re responsible for that. The HSE cloning down hospital beds and A&E, we’re responsible for that. The HSE tells lies about us and the papers just re-print their PR without even the most cursory check.”

His voice was starting to rise slightly. “The IPU wanted to talk about a new contract for the last five years and the HSE refused to talk. And somehow we’re responsible for that.” His voice was cracking. The stress of the last few months was getting to him now. He had re-mortgaged their home to start the business and this was now at risk. He was finding it difficult to meet the monthly re-payments on the business loan. There had been one too many “friendly” phone calls from the bank manager just to see how he was getting on. A few of his friends had been pulled in by the KGB that goes by the name of the Competition Authority. I wonder when it will be my turn. “Damm, why did I ever stick my head above the parapet?” It was funny how they were set up by Mary Harney and now they denied that their raids on pharmacists were at the instigation of the HSE or the Department of Health. Mind you lying wasn’t anything new to any of them now. They lied to the media, they lied to the Dáil. It got to the stage where the HSE and the Department were so used to the lies that they probably believed every lie themselves.

He hadn’t noticed that his arms and shoulders were shaking. “It’s OK Brendan, we’re here for you.” One of the others put his arm around him and consoled him. That was one of the few good things to come out of this unholy mess. Pharmacists were together. They couldn’t all act together, that might be anti-competitive. But they were there for each other. They might disagree on what had to be done but they were all agreed that something had to be done. As one old timer put it, “When it starts to rain everybody puts up their umbrella or runs for cover. It doesn’t mean that they were colluding, it’s just that it was the right thing to do at the time.”

There wasn’t much more to the meeting after that. A few announcements about upcoming events and the role that those present could play. Everybody put away their chairs and made their way to the door. As they shuffled out they all knew that they would most likely be back again soon. Not that they wanted to be, but the comradeship of Pharmacists Anonymous was the best support group any of them could find.

June

Reviewing the war

So there is a cease fire in place. Pharmacists have pulled back from the brink and the HSE have promised that they will be good boys now. As Winston Churchill said “this is not the beginning of the end but the end of the beginning.” So now is a good time for the armchair generals to sit back and review how the war has gone so far and where it is going next. Except in this case none of the generals are sitting in armchairs. They are all standing at dispensary counters trying to run a business as well as the business of running a war.

So how did the various battles go? From a public point of view the PR battle was probably the most visible. For me this was always like the US army against the Taliban. One side has a much larger arsenal, much deeper pockets and doesn’t mind using lies and dirty tricks. It still doesn’t mean that they are going to win. The print media in particular seemed to take a fairly submissive attitude to the HSE right from the start. I suspect that this may have to do with the HSE threatening, as they did with Newstalk 106FM to withdraw their advertising from any media that did not give them an easy ride. And apparently they did have a big spend in the media. Certainly at the start many of the articles in the national papers at least seemed to be straight forward cut and paste from HSE press releases. It looks like the press lost their ability to check facts and figures or do some basic research.

But the HSE didn’t have it all their own way. Well prompted questions from TDs and Senators gave them some uneasy moments. Some of the Sunday papers took the time for more reasoned and researched articles which were balanced at least. The HSE seemed to shy away from live interviews on radio. Who could blame them when we heard Pat O’Dowd being mauled and eviscerated by Pat Kenny and Irene and Michelle. It was a joy to listen to.

I also think that in this case the national press mis-read the public’s view of pharmacists. The press loved having a go at the rich pharmacists who were living it up at the tax payers expense. But Mrs Murphy or Mrs Kelly didn’t see a rich pharmacist. They saw David or Rosemary who stands in the pharmacy every day. Who helped them out when they came home from hospital and the surgery wouldn’t have their GMS script for a couple of days. Who was able to explain to them about their medication in a calm unhurried manner. Who delivered their prescription to their home when they were unable to get out. Who took time to explain to them exactly how they were paid by the HSE for those medical card scripts. These were also the people who had extensive experience of the HSE. They regularly attend out patients in the various hospitals. They are on waiting lists for various operations. The support for their local pharmacy and pharmacist was steadfast.

These same patients have to be thanked as they managed to swing the TDs into action. Very quickly Fianna Fáil TDs in particular realized that there were few enough votes to be won by sorting out the HSE mess but there was a hell of a lot to be lost by not sorting it out. And those approaching them were the over sixties demographic who still see voting as a civic duty.

It’s probably worth taking a few minutes here to look at the attitude of the various political parties to all this. Fianna Fáil were a split party. The back bencher’s saw that this had a lot of potential trouble. And they were rightly bothered by this. However they were soundly whipped into place by the government. The ministers were and still are supporting the HSE. This is not surprising as the HSE is supposed to implement government policy. However at times it looks like the HSE tail was wagging the government dog.

As for the PDs what more can be said. The smallest party to ever hold a senior cabinet position, They could hold a party meeting on the back of a Honda 50. SWMBO Harney, more Boston than Berlin, sets up the Competition Authority and then moves to the Department of Health.

As for the Greens, this had nothing to do with the environment so go away and let me eat my muesli on wholegrain sandwich in peace.

Fine Gael while eager for a stick to beat the government with could just as easily stood on the other side of the fence. Indeed some of their spokespersons are so right wing as to make SWMBO Harney look like a pinko lefty.

For me the Labour Party was the only one to shine. They quickly could see that the issue was one of the right to representation. I am interested to see where they stand now that the Department of Health at least has accepted the IPU’s right to negotiate on behalf of it’s members.

So how did the HSE do? They read the situation in pharmacy wrong. They had a badly thought out plan. They had no plan B in case plan A failed. They lied and mis-represented facts. They relied on the “Might is Right” principle. Essentially they behaved like Leeds United supporters, “Everybody hates us, but we don’t care!” There are only two bodies that can put manners on them. The Department of Finance who they report to. They put up their hands all innocently and say “We have nothing to do with it, it’s all the HSE’s fault.” It seems that nobody wants to take political responsibility anymore. I would have more respect for the politician who stands up and says “It’s our policy that they are implementing. If you don’t like it, tough!”

The other group who can put manners on them is the Courts. That however is a long term game. We all await that one with baited breath.

So what about the next phase of the war? To use a phrase from WW2 “Loose talk cost lives.” The HSE haven’t been smart enough to call it right so far, and I have no intention of helping them out now.

As for me I’m going back to my war board and air-fix models. I’ll play out some past scenarios and postulate on new ones. Instead of the weapons being put beyond use I’m oiling and cleaning them. And the next time our collective aim will be better. Practice makes perfect. To para-phrase another revolutionary “We’ve not gone away you know.”

July

I have been thinking of alternative careers that I might follow if the world of community pharmacy goes belly up. This is all part of what I call prudent planning. Another name would be panic planning. As I said in an earlier article my needs are few and simple. Enough to feed & clothe my family and myself, mortgages paid off and a little put by for retirement. The first stages of my planning seemed to be reasonable and logical. But as with all plans there is always a flaw or two.

The first and most obvious option is to do what I’m doing now only for somebody else. I admit that it would be a big wrench for me to go from sixty hours per week to forty or forty five. I’m sure that I will get over the initial boredom of having time for family and a life. One of the flaws in this plan is that current salary levels are unlikely to be maintained. However this is countered by the fact that I am damn good at what I do so I am head and shoulders above my competitors in this field. A variation on this plan would be to take up full time locum work. This might not be stable or plentiful enough to meet my needs. This coupled with the down ward pressure on locum rates made this variation less preferable.

My next option was still pharmacy related. Make more use of my excellent B.Sc.(Pharm). from T.C.D. and start a new career in the pharmaceutical industry. The flaw in this plan is that I would need to get some experience before I reach Qualified Person status. But at least my degree leaves the option of QP status open. This may not be available to all of the pharmacy degrees currently on offer. A slightly more significant drawback in this plan is that the knowledge earned getting my degree may be slightly past its best by date. This was brought home to me following a conversation I had with my pre-reg. Over tea and bickies we were discussing various aspects of pharmaceutical chemistry and pharmacognosy, as you would. It quickly became apparent that large portions of the current course had not been discovered when I was in college. All of a sudden I was beginning to feel old.

My thoughts then developed further as I considered a return to retail, plain and simple. I started my working life in Superquinn and one way or another I have been involved with retail for over thirty years. I have loads of experience there and also there is no need for a locum when ever I wanted a day off or heaven forbid a holiday. One of the newer German retailers in the Irish market recently advertised for managers. The salary on offer was more than I am currently taking from the business for myself. I looked for the flaws or pitfalls in this plan and to be honest they are few and far between. I almost find myself filling out my application form straight away.

I then decided that it was time to think out side of the box. What other skills do I have that I can use to turn a bob or two. This is an interesting exercise to do at any time regardless of the current HSE terror tactics. One that I hadn’t thought too much about would be my skills in project management. Over the last fifteen years I have been involved in eight pharmacy fit outs. Add to this overseeing the build, fitting out and decorating of two new houses and the building of a new kitchen and extension. Up to this I would not have considered this to be a skill. It was just something I had to do. However when I finish writing this article I’m going to do some research on the going rate for project management.

Another method is to look at your hobbies and see if you can turn these into money makers. This can be a risky move as it involves turning a relaxing hobby into a potentially stressful salary earning career. Shakespeare put it well in Henry IV Part I (Intermediate Cert 1976) “If all the year were sporting holidays, then to sport would be as tedious as to work.” So what are my hobbies? The first would be motor biking. The only obvious career here is to become a motor cycle courier. My current bike a CB500 is a suitable choice for a courier. I already have all the wet and dry weather gear. I have a good knowledge of Dublin and the hinterland having lived here for over 40 years. The downside is the dangers involved in motorbiking in Dublin. As long as you are faster than the cars, buses and lorries that are trying to hit you you should be OK. At least there is nobody coming after you with guns, knives, blood filled syringes etc On second thoughts it might be a safer career choice.

Or I could do what I’m doing now, wring article for publication. Maura is there any jobs going there in Green Cross publishing? I’m very versatile, I can write on any subject and make it sound convincing. Indeed with the world wide webby thing you can research any subject and become an expert overnight.

My other main hobby is internet poker. In terms of money this is the wild card. If I was to play successfully five nights a week (and it would be a night time job) and make say €200 a night. That’s €1,000 per week or say €50,000 per year. As this is tax free it is the equivalent to about €75,000 salary. Not a bad living. No locums needed, most of the day free, work from home, what more could you want? Yes you are taking a bit of a gamble but I reckon that is no bigger a gamble than having to sue the HSE in the High Court. And at least with internet poker the rewards are instant, no waiting for the Supreme Court in two to three years time.

So as you are reading this I am most likely enjoying our first decent family holiday in three years. My holiday reading a four books on poker theory and styles of playing. So depending on how things go with the HSE if you want to keep reading my articles you might have to switch to “Poker Monthly”.
If are are a potential employer in any of the above categories please consider this to be a CV.
When published this was followed by an editorial note, “Thank you for your CV, it has been passed on the HR department.”

September

Methadone again!

 

Back at the start of the year I wrote about my experiences with the Methadone Scheme. And it is with a slightly heavy heart that I return to the subject. Back then I said that the Methadone Scheme would put my kids through college. But that looks no longer to be the case. The way things are going I don’t think that I will be involved with the scheme by the time that my kids do the Junior Cert, never mind the Leaving. And here is why.

There is no need for me to re-hash the promises made last October and April. Suffice to say that they have not been kept. I was informed by phone that items which do not attract a discount, like methadone, would not be reduced by 8.2%. Well those involved in methadone at the HSE level should of informed the PCRS about this. Because my payments for March and April were both down by the same 8.2%. I was paid properly for May but as I write the March and April shortfall has still not been paid. This however only re-enforced my decision as per usual the payment sheets were woefully slow in coming out.

The genesis of my decision was made during the first week of May. I had informed the Central Treatment List (CTL) that amongst other actions I intended withdrawing from Methadone on May 1st. There then followed the great Pharmacy Social and show piece with a pre-determined out come in Liffey Valley on April 30th. So the following morning I rang my liaison pharmacist and I told him that although I didn’t agree with the previous nights decision, it was a democratic(?) decision and I would abide by the will of the majority/IPU executive. As part of our side of the agreement all pharmacists were asked to lift any threat of suspensions or withdrawal of service. I was in a position to continue supply to the clients on my list. No need I was told, they have already been allocated to other pharmacies. This was news to my clients and their doctors who hadn’t been told anything. Thursdays had always been my busiest day methadone wise. And one by one they trooped in for their prescription. I rang the CTL for advice and left a message on voice mail. After an hour with no return call and two methadone clients sitting patiently in the pharmacy I decided to dispense to them as normal. Over the next weekend three of my clients failed to show and I haven’t heard from them since. I was philosophical about this. There are always casualties in war and I can take this hit. About a week later I received a letter from the CTL including a new card for one of the disappeared.

Roll on June and I receive a letter from CTL, dated 5th June telling me that the following seven clients will no longer attend my pharmacy. This included the three that disappeared during the first week in May. It also included four who still attend. I did not open this letter until the third week in June as I was away on holidays. So what was I to do? Tell these clients to contact the CTL and find out where they were to go. Neither they nor their doctors knew anything of this. No I just ignored it and carried on as normal.

About this time like many other pharmacists I was looking for ways to make cuts adjustments. This time last year along with my wife and myself I employed three full time. Now it is two. I decided to see if I could cut back on my opening hours to save on costs. Closing earlier was out as most of the methadone clients called in the evening on their way home from work or college. Eventually Saturday afternoon was chosen after some discussions with the clients who attended on Saturday. It was then that it struck me. My opening hours were being determined by my methadone clients!

While on a personal basis I have good relationship with many of them I draw the line at them dictating how I run my own pharmacy. So I decided on a gradual withdrawal from Methadone. I am not taking on any new clients and as the current ones leave they will not be replaced. Already due to natural turnover I now only have four left. These four I will see out to when they come off methadone, end up in Mountjoy, move out of my catchment area or reach a happy retirement.

Much of what I wrote last January about the Methadone scheme still holds true. It has been successful in reducing crime by addicts. Pharmacists and GPs do provide a more humane locally accessible service. Pharmacists provide the service on a more economic cost efficient basis. For the HSE the Methadone Scheme is still eaten bread, soon forgotten. But now they have played us for a fool, twice!

I think that the time has come to let Methadone wither on the vine. Look after your current clients but refuse to take on any new ones. If certain foreign (and some Irish) owned chains want to take on more Methadone clients, let them. They are welcome to them. The HSE has shown that beyond getting them out of the clinics that they don’t care much. It’s time to remind them that they could not manage in 1996 when the scheme started and they can’t manage now. Pharmacists got them out of a hole then and if they want to stay out of that hole they better start behaving. It is not in pharmacists interests for the scheme to continue as at present.

So the Methadone scheme may not put my kids through college but it will provide me with plenty of material for these articles.

October

Qui custodiet custodiens

 

Prior to the debacle that is the HSE’s cuts I had hoped to take some time off from the pharmacy. Not being in a position to employ a pharmacist full time I thought that I might be able to arrange it so that two or three of us together could employ somebody full time and split the salary costs pro-rata. Hearing on the grapevine that EU pharmacists could be hired for less I decided to investigate the requirements so we might get a EU pharmacist registered to practice in Ireland.

My first port of call was the web site of (cue deep bass voice), THE REGULATOR. That’s the PSI for those of us who still operate in pounds, schillings and pence. This did not help me much so I sent off an email asking them for some more details. In particular I asked

“Particularly in relation to background checks in relation to their degree/diploma/qualification and how it meets Irish requirements to practice pharmacy and their knowledge of Irish Pharmacy law.
Also in relation to background checks on the pharmacist as to their suitability, e.g. police or criminal record checks or fitness to practice checks.
Given that patient safety is now recognised as being paramount and communication with patients is vital in this respect what checks are made to enquire if the pharmacists are able to communicate in English or Irish effectively?”

After about three weeks I received a fairly comprehensive reply. On the basic qualification and good standing status the procedure is relatively straight forward. The relevant competent authority in the applicant’s home member state is required to confirm the pharmacy qualification and the relevant competent authority in all states in which the applicant is registered or has been registered at the time of application is required to confirm the professional status of the applicant and their ability to practise as a pharmacist without restriction. The PSI requires both of these confirmations to be sent directly to the PSI by the competent authority”

The reply did not address how they are required to demonstrate a knowledge of Irish Pharmacy law. I shall return to this later. On the issue of linguistic ability the answer was a bit more vague.

the Act requires EU/EEA nationals who lack the linguistic competence necessary to be a registered pharmacist in Ireland to give an undertaking to acquire the necessary competence, and where an EU/EEA national gives this undertaking, the PSI has the power to impose a condition on their registration mandating that they acquire the necessary linguistic competence before practising in a way that entails dealing directly with the public……draft Regulations governing pharmacy premises and practice standards which are in development by the Department of Health ………the PSI understands that an obligation will be placed on pharmacy owners and superintendent pharmacists to be satisfied that all pharmacists and other staff employed or engaged have the necessary language (and other) skills to perform their responsibilities.”

So effectively all they have to do is to put their hand on their heart and say in their native tongue “I promise that I will learn English (or Irish) as soon as possible.” It then the PSI passes the buck saying that it is the responsibility of the pharmacy owners. Rather it will be their responsibility if SWMBO Harney does what she has hinted to the PSI that she might do. I replied asking

“Can you tell in what circumstances you can envisage somebody practising pharmacy without coming in contact with the public? What follow up is carried out to check that they have indeed acquired linguistic competence. I know that it is early days for the Pharmacy Act but has the PSI received any complaints or imposed any restriction on the practice of any pharmacist on language grounds?” To date they have not replied. I also asked in my reply about demonstrating a knowledge of Irish Pharmacy Law. I still remember the rigorous forensic exam that I has to sit (and pass) many years ago. I presume that the PSI will say that this comes under “..(and other) skills..”

So there you have it. The PSI, “THE REGULATOR” who’s primary concern is public welfare say that we cannot ensure that pharmacists can speak English or that they know the basics of Irish Pharmacy Law. It conjures up an image of the residents of Shrewsbury Road running around in circles with his hands over his ears singing “la, la, la, I can’t hear you.” In this regard I have heard of instances where a prescription only item was sold OTC in Dublin by a UK pharmacist. OTC sale of this item is permitted in the UK. I have also had to contact pharmacists whose English was barely passable to check some patient details. It is up to the pharmacy owners to ensure pharmacists have a working knowledge of English and Irish Pharmacy Law and we all know that they will be diligent in this regard.

To be fair to the PSI it may not be all their fault. The EU has free movement directives allowing for all this. Indeed it may be illegal to discriminate against an EU citizen in an employment situation because of their linguistic or lack of linguistic ability. I wanted to ask the Directorate General for Health and Consumers how they feel about EU directives being used in such a way which may put patients and consumers at a disadvantage? I also wanted to ask them was there any other country in the EU that would allow me to practice pharmacy without demonstrating a working knowledge of the local language or local pharmacy laws. I tried checking the relevant pharmacy regulator web sites but my lack of any other language prevented me from getting any further with my enquiries. However the mailbox of the Directorate General for Health and Consumers is closed for the summer! So we will have to wait for them to return from their holidays to get their view of this.

November

I’ve been thinking about pharmacology a good bit lately. That’s not too surprising considering what I do for a living. Two drugs in particular, diazepam and flurazepam. That’s because I have been getting a lot of prescriptions for them in the recent past. What could people be suffering from that would need such a large quantity of scripts for these two. So I consulted my BNF. Insomnia, panic attacks and anxiety are the main indications. Then it occurred to me that these patients must all be pharmacists who have to deal with the HSE on a regular basis. I could certainly recognise many of these symptoms in myself following many of my run ins with the afore mentioned body. But then none of the names on the scripts seemed to appear on the PSI’s register. This would seem to run counter to the Presidents of the PSI’s argument that many of us are junkies and addicts. It was at this point of the dispensing process that a little bell went off in my head. As both of these drugs had potential for abuse maybe the prescriptions weren’t genuine. So in accordance with my dispensing S.O.P. I tried to contact the prescriber. But all of these were presented outside of surgery hours and the doctor was not contactable.

Those of you who live in the real world of pharmacy today would realise that I jest a little. However the problem is all too real. For me at least it falls into two types. Firstly there are the forged scripts and then there are the genuine ones but presented by folks that you would rather did not frequent your pharmacy.

The forgeries are the simplest to deal with. There is no way that they are being dispensed. For me the best case scenario involves retaining the forgery and the presenters being taken away in the back of the squad car. Alas this does not happen often enough. On a couple of occasions the boys in blue just arrived in time to see the perps running away at a speed that would do Ben Johnson proud. I usually try and stall for as long as possible to allow for the arrival of the Guards however on many occasions I have had to deal with demands that I return the forgery to them. Then it is time for the second best case scenario. Retain the forgery and get the perp out of the pharmacy. It is at this point that most of the perps become aggressive when they realise that they are not getting their precious piece of paper back. I can understand why many pharmacists when faced with this aggression fear for their own and their staff’s safety return the forgery in the hope of getting the perp out of the pharmacy. As for me, it’s my territory and I ain’t taking no crap. I have the advantage of a large physical presence, a voice which can command an authoritative tone and a fluency in Dublinese which can indicate in their own tongue that I wish them to leave my pharmacy right away. I have built up a collection of CCTV clips which I have shared with the Guards of me doing just that.

The genuine one present a thornier problem. They are nearly always private scripts, I have never seen a genuine GMS one, and always seem to be written by a limited number of doctors. I am assuming that most of these are genuine as I would be familiar with the doctors hand writing and their style of practice. However even when presented at regular hours many of these doctors still are not contactable. This presents a ethical and moral dilemma. Here we have a genuine script being presented by somebody who is very likely to misuse them. We don’t know if it was written under duress or as with the pharmacist above as a result of a real or presumed fear for their own safety. And it is usually presented by somebody who we would prefer not to have in our pharmacy. To date I have not dispensed these scripts. I inform the presenter that I am unable to confirm that it is genuine as I cannot contact the prescriber. This gives my least preferred scenario. Give them the prescription back and watch them leave the pharmacy. Probably to move on to another pharmacy where they can intimidate some other pharmacist into dispensing the script.

What is to be done? I contacted the Medical Council to see if something could be done. Their response was that I could make an official complaint in writing about the doctor in question which the doctor themselves would be able to see and quiz. I did not wish to go down this route for two reasons. Firstly I was unaware of the doctors motivation in writing these scripts. Secondly making a public complaint about a doctor is tantamount to professional suicide for a pharmacist. After some letters back and forth with the Medical Council I came up with a Jesuitical form of words.

“It is not my intention to make a formal complaint against Dr XXX, I was just bringing to your attention some facts that I thought that you should be aware of. Something akin to witnessing a suspicious act on the street and reporting it to the Garda Síochána.”

Maybe it is time to diazepam and flurazepam to the controlled drugs list. Certainly diazepam 10mg and flurazepam 30mg as these seem to be the preferred choice of the junkies. Unauthorised possession (including possession as a result of a forged prescription) should be treated the same as heroin or cocaine possession. Then for good measure they should be hung, drawn and quartered and then lock up what’s left and throw away the key. Maybe that’s a bit harsh. Let’s just make them part of the IPU’s team that negotiate with the HSE. That would be torture enough for any body.

December

Hail to the chief.

I have been watching and listening to all the coverage of the US elections. To be honest it would be kind of hard to miss it. As I write Obama has been hailed the victor. So I asked myself “Does this have any implications for Irish Pharmacy and Irish healthcare?” Probably not, but this doesn’t stop me using it as an attention grabbing headline for the article. Then I though a little bit more about it. Maybe what Irish pharmacy and healthcare needs is an Obama like figure. Somebody to unite all strands in the healthcare arena. Somebody to work out a common goal and get all sectors to work towards it. To put our differences behind us, inspire confidence and move to a bright new future. To use the words of our beloved Minister for Finance “It is nothing more than our patriotic duty.” Instead we got SWMBO Harney and Professor Dumb & Dumber. Their inspirational catch calls are “It’s my way or the highway” and “Trust me I’m a doctor.” To be fair to SWMBO she probably does have a view of where she would like Irish healthcare to be. But unfortunately the only group that shares this endpoint are the developers looking for tax breaks so that they can build more yellow pack hospitals. She wants a Boston type health service. In practice this means that you better have private insurance or lots of money. I guess that she is getting her way.
As for Dumb & Dumber it would be unfair to say that he suffers from a god complex. More accurately the Irish public suffers from his god complex. He moved from a world where his word was gospel to one where his word was “the basis for further discussion.” Maybe he should have stuck with looking after sick children rather than making the rest of us feel sick. I wonder what skills he had to demonstrate before being appointed head honcho of the HSE. Off the top of my head I could think of a few. The ability to work with professionals from disparate backgrounds. The ability to deal with a massive budget. To be best buddies with the Minister for Health. Have a guess which was of highest priority when they sat down for that interview.

But where would this messiah like figure come from? Perhaps we could get somebody from the world of business. Maybe somebody from the world of pharmacy. There are a number of pharmacists out there who have built up large chains from humble beginnings. They would have experience of massaging with doctors egos, negotiating the labyrinth that is the HSE bureaucracy and trying to work out who does what in hospitals. The real problem with this choice once they had got the health service sorted out and efficient they would then sell it off to the first British, German or Dutch multi-national that makes them an offer. Then take a slice of the profits and retire again. The first figure that came to mind when I started writing this was Michael O’Leary. Could you imagine what kind of health service he would run. “Do you want an extra blanket on your bed? That will be €10 please.” “A fresh bed pan? €10 please.” “You want to see a doctor? Oh and you want to talk to him as well?, €20 for that.” “Don’t bother asking to see a consultant, your credit card has already been maxed out.” If your ambulance is delayed getting to A&E there is an extra charge. If you get sick or have an accident just before Christmas you better have a rich relative. You may not like the resultant health service but there is no doubt that it would make a profit.

Alas I feel that we might be stuck with the current bunch. I think that the long term plan is to have a health service that is so bad that people either take out private insurance or die. And from the HSE’s point of view dead patients don’t cost them very much. Just think of the savings that could be made then. The mind set from HSE Ivory Towers must be along the lines of “We could run a wonderful health service if we didn’t have all these patients to treat.”

And to finish a bit of dessert. And for dessert a piece of humble pie. In a previous article I was a bit harsh on the PSI. And may I say that this part has not been inspired by any snap inspections that I may or may not have had in my pharmacy. I took them to task for not insisting that EU pharmacists registering in Ireland had sufficient competence in the English language. It was unfair of me to single out the PSI for this. The reality is that every pharmacy regulator in the EU deserve a piece of this stick. The common thread is EU Directive 2005/36/EC. This essentially says that all we have to do is to show up with our Certificate of Competency and a Letter of Good Standing and hey presto we can register anywhere in the EU. Some of the regulators make it a bit more difficult by only making this information available in their local language on their websites.
What you may ask is the European Commissions view of all this. The EU Commissioner for Consumers has said that this is not part of their portfolio and as such has no opinion on the matter. I pointed out to them that patients are consumers either by paying healthcare providers directly or indirectly via taxes or insurance but this made no difference to them. And the Commissioner for Health and Healthcare Issues, well they still have not replied to my email after more than 10 weeks despite reminders. However I’m not letting this rest. I am like a terrier who has just got his teeth into a juicy bone. I’ll not stop until I bite through to the marrow or break my teeth in the attempt. So look away now if you have a weak stomach.
If you are still reading then I will see you next month.


 

 

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