2010 Articles

anuary

What is a pharmacist worth?

I was having a conservation with a colleague the other day. He is currently doing locums to keep body and soul together. I mentioned that somebody of my acquaintance was earning €21 per hour doing fairly bog standard paper pushing role in a semi-state. I could feel the steam coming out of his ears as he related to me that he was only being offered €25 per hour for all his locums. No holiday pay, no permanency and all on emergency tax. Doubtless there are pharmacy owners out there who are taking advantage of the over supply in the employee pharmacist market to drive down rates. They probably still feel a bit sore at having to pay the higher rates when supply was tighter. My friend while acknowledging the situation felt a bit hard done by as he had returned to college, paying full fees putting his first career on hold. I told him that his situation was akin to those who had bought property at the height of the boom. He was in a form of career negative equity. He had put more into becoming a pharmacist than he was ever likely to recover through increased earnings. But to me this begged the question, what is a pharmacist actually worth.
Earlier this year I saw some figures from a Time & Motion study carried out by Unicare on the dispensing process. They worked out that it took 9 minutes and 9 seconds to complete all the steps involved with dispensing an item. Of the 10 steps that they had identified there were 4 or possibly 5 which could be assigned to support staff if you were lucky enough to have some. The outcome of this is that a pharmacist working on their own leaving many of the administrative tasks to support staff could safely dispense approximately 10 items per hour or about 80 items for an 8 hour working day. Now the HSE in it’s wisdom(?) has decreed that the dispensing fee should be €3.50 per item. So a pharmacist working flat out could generate €35 per hour. Considering the costs of running a pharmacy this makes €25 per hour seem generous. All this assumes that the pharmacist is working flat out. As the pharmacy becomes less busy, approaching about 60 items a day the income generated does not even cover the cost of a pharmacist. All this fits with SWMBO Harney’s view that pharmacists should be little more than pack and wrap. It also fits with her desire that 600 or so of the smaller pharmacies should close. On the face of it we have no restrictions on pharmacy openings. However the Minister for Health is effectively pricing the smaller businesses out of the market. And who owns these smaller pharmacies? The majority are Irish owned independents. And who owns the bigger survivors? A good proportion are part of foreign owned chains. So you want to close down Irish owned and operated businesses and leave a razed field for foreign multi-nationals. What a way to go Minister, you should be ashamed to call yourself Irish!
But I digress. I return to my original question. What is a pharmacist worth? In an ideal world a persons salary would reflect the value of the work that they do. In an economy the salary also reflects the availability of a given profession. At the moment we have massive over supply. 170 Irish graduates per year, at least the same number again of Irish graduating from UK universities and chains actively seeking employee pharmacists in eastern and southern Europe. We have a Minister for Health who knows the price of everything and the value of nothing. It is no wonder that she doe not value the work of pharmacists. I would doubt that she even knows the work that we do. I suppose that is what comes from spending her entire career outside of the real world. Everything that she sees and hears is filtered through civil service eyes and ears. I would be surprised if she could find her own way home using public transport. That’s presuming the other passengers didn’t lynch her first. As I pointed out in a previous article we have some chains who are so desperate to reduce costs that they are content to have pharmacists who cannot speak English properly. How some of these pharmacists can counsel patients, particularly any with poor hearing is beyond me.
But to get back to my starting point from a pharmacoeconomic point of view it would be a relatively straight forward exercise to put a value on the work done by pharmacists. It would also be easy to put a value on all the extra work that we could be carrying out. There is no need to list them here again. However we have a Department and Minister for Health that seem to have some kind of mental block when it comes to utilising the skill set that pharmacists have. They see a crisis as a time to panic rather than a time of opportunity. I have to return to my theory that when she was growing up her local pharmacist did not give her enough lollipops or she must have had her heart broken by a pharmacy student when she was in college. And what of those currently in college? Long nights slogging to get 600 points and all they are looking forward to is a career in an industry with no real long term security and employers who put low salary ahead of ability to communicate properly with patients. If you are one of those who are currently paying to get a degree in pharmacy as a second career I would advise you to think long and hard and maybe cut your losses now and return to your original career. Don’t pursue a career just because of the salaries that you might have heard about. Do it because it is what you want to do with your life. High salaries will always come down and all you will be left with is job satisfaction. Until such a time as we have a Department and Minister for Health that are willing to recognise pharmacists skills all I can say is the worth of a pharmacist is beyond price but the price of a pharmacist currently has no worth.

February

Codeine Guidelines, window dessing(?)

I took the time to have a read of the “Non-prescription Medicinal Products containing Codeine: Draft Guidance for Pharmacists on Safe Supply” It had all the appearance of doing something for the sake of being seen to do something. It reminded me of when they announced that 10-15% of pharmacists would have addiction problems at some stage. The perception given out at that time was that we were all junkies. This time the perception was that anybody who takes a codeine containing product is an addict. I have already had one patient refuse to take a codeine containing product that was prescribed for her because in her words “I don’t want to become an addict”. I think maybe that Ambrosia Creamy & Nice and the PSI should spend some of our hard earned fees on getting some proper PR advice and then following it.
Getting back to the draft guidelines, the first key point is that these products should be stored out of sight in the pharmacy. This is probably the PSI’s version of out of sight out of mind. This might have some effect if the general public did not know about these products. But while these products themselves may not be advertised directly to the public a large number of their namesakes are. These products have a level of brand recognition that most PR people would give their right arm for. Reading the rationale for this one thing bothered me. The current regulations state that they must not be available for self selection by the public. It would now seem that the PSI has interpreted this to mean that as well as physically inaccessible they must also be visually inaccessible. This is a big legal leap by the PSI. They have taken an interpretation which to my mind is legally dubious, seek to put it into guide lines which will be enforced by the Code of Practice which in turn can be used to discipline pharmacists. I could see our well heeled legal colleagues having a field day with this one if they decide to haul somebody over the coals on this basis.
The second key point is that they should only be recommended as second line products. This would seem to imply that most pharmacists reach for these first when recommending an analgesic to a patient. I find this assumption most patronising. But I have come to expect this from the current PSI. One of the reasons that these products are popular is not that they are addictive but that they are effective analgesics. Saying that we should not recommend these unless other simple analgesics have been shown to be ineffective is like saying that a car sales man should not sell a BMW to a client until they have driven a Skoda for a few days. Patients will very quickly learn the “correct” way to ask for a packet of these products. “I’ve tried paracetamol for a few days now but it has not fully effective. I would like a pack of (insert preferred potentially addictive analgesic of choice) and yes I am aware of the potential risks associated with misuse.” This makes the entire process a form ticking exercise and would very quickly become a laughing stock.
The next key point shouldn’t even needed to have been put into the document. The maximum pack size of 24 means that anything other than short term use necessitates repeat visits to the pharmacy. Even without these draft guidelines this is something which would precipitate a response within the pharmacy.
While the draft guidelines second key point is patronising to pharmacists the fourth one is patronising to patients. Yes some patients need to be advised on the correct use of these products but many more if not most, are fully aware of how they should be taken. By insisting that we counsel everybody on risks associated with misuse we will lose our credibility with the public if we start treating everybody as a potential addict.
All this presumes that patients are ignorant about their own condition and their own response to various medicines. If they know the risks then they can make their own decisions. We as a society already accept this for alcohol and tobacco. Combine this with hiding them away in the pharmacy and we end up treating patients like children. And we are pharmacists, not nannies.

So enough of the negativity how about some positive suggestions. The first thing I would like to see is the current regulations being enforced. And this means for all pharmacies and not just those who are not in a position to hire some high faluting lawyers. We are all aware of pharmacies that offer cut price medicines including codeine containing ones, have in store and window advertising, hand out leaflets and have codeine containing products available for self selection. If these pharmacies treated these products with a bit more responsibility then the need for the PSI to be seen to do something would undoubtedly be diminished.
The next is outside the PSI’s remit but I’m sure they could bring their influence to bear. While these products are not advertised as I wrote above their namesakes are. So the PSI should push for a ban on advertising to the public of all the namesake products. To go one step further when the product licences come up for review the manufacturers should not be allowed to similar names for dissimilar products. Also phrases such as “Analgesic from the makers of….” should be banned. This might not go down too well with the drug barons (big pharma) but the PSI (and the IMB for that matter) have to decide who they serve, the public or the multi-nationals.
However by the time you read this the draft guidelines may already be finalised and the law of the land. I sincerely hope that the PSI listen to the beleaguered pharmacists at the coalface and bring a little more realism to this matter. So for this reason I am breaking the habits of a life time and I intend to make a submission along the lines of this article to the PSI. How they will take this I will never know. But at least I will have done my bit.

 

March

It was going to be one of those days.

Monday morning, a new week starts. It was only 10AM and already the scripts were piling up. Next up was Chrissie. We dispensed a hospital emergency script for her on Friday. She had been discharged from the local hospital with a completely new set of meds. Her script was for all her old meds dated two weeks previous. “Here we go,” I said to myself as I dialled up the surgery. “He’s very busy right now,” was the receptionist’s reply. “I’ll ask him to ring you when he has a few minutes.” It was a good job that Chrissie was calling back and wasn’t in a hurry. So I put it to one side and moved on.
A couple of scripts later up comes Old Joe. Joe had been coming into the pharmacy for as long as the pharmacy had been there. And as he got older his list of infirmities and his resultant meds got longer. Three prescription forms and over 20 items. There was one or two there that I was fairly sure that he was not taking, either by design or oversight. I was going by the amount that his daughter asked us to dispose of when she carried out the annual clear out. Aware that the prescription tax was due to start soon I decided to see if we could rationalize this a bit and maybe save Joe some of his hard earned pension. So I approached him as he sat waiting. “You know that this is going to cost you a pretty penny once Harney brings in her prescription tax. How about we try and cut these down a bit.” He’s game for it so I arrange for him to come back on Wednesday afternoon when things will be a bit quieter as the docs are all playing golf and we can sit down and go through everything. It might cost me some turnover and save the state a bit of money but Joe will be the better for it. “It would be nice to paid for this work” I thought to myself.
I got back to the dispensary to find my first mug of tea of the day going cold. I will be going into caffeine withdrawal before this morning is out. Just as a fresh hot steaming mug arrived the phone rang. It was Dr. Morris returning my call. “That was quick” I thought to myself. He is a nice chap. Young, he had recently taken over a run down practice when one of the old school retired. “Sorry to have taken so long to get back to you” he started. I explained the situation and without hesitation he asked me to dispense as per the hospital discharge script. “Fax it over to me and I’ll get a GMS made out ASAP.” I also explained that I had dispensed most of it generically as I didn’t have many of the brands in stock due to the short notice at the weekend and the previous IPHA messing about. “No problem,” he says. “You can switch any of mine generically any time you want, just use your judgement. And while I’m on to you I might as well give you my mobile number in case you need to get me out of hours.” This day was looking up.
It was just lunch time and one of the front of shop girls ran over and got me a sandwich from the local deli. I sat down in my office with the paper and a third fresh mug of tea wondering how far I would get before I would be called out. Result, sandwich and tea finished and a decent chunk of the paper read.
So it was back to the counter for the afternoon onslaught. It actually wasn’t too bad. Things were moving along nicely when there was a phone call from Doc Murphy. “It was too good to last,” I thought. He was in a local nursing home with one of the residents. She had an infection and she wasn’t responding to his preferred antibiotics. He had sent a sample off for culturing and had the results which he shared with me. We had a brief discussion about local antibiotic sensitivities which I had to hand from the local hospital. We agreed a new course of treatment and he said that he would drop the script in on his way back to his surgery.
This day couldn’t get any better I thought. In the background I heard the evening news programme start on the radio. They were promoting the investigative current affairs programme for later that evening after the main news on the TV. Harney’s campaign funding irregularities. It seems that they had found evidence that Big Pharma drug companies had been making contributions to Harney’s election funds going back to her days in the Department of Industry. All above board of course but it called on her impartiality when dealing with these companies now. As usual the opposition spokesman was calling on her to resign. Interestingly he also said that if they really wanted to save money in Health then they should be talking to those at the coal face, the pharmacists and GPs. They would be able to show them how to save money and introduce value for money new services that would save the country money in the long run.
I had to savour the moment. I sat back and closed my eyes as I listened to the opposition spokesman tear into Harney’s credibility. I must record this programme tonight. A hand grabbed my shoulder and shook it roughly. “WAKE UP, WAKE UP! You are going to be late for work again.” It was 8:00AM on Monday morning and the rain was beating down.

 

April

No speaky da Inglish II

Around this time last year I wrote about one of my pet peeves, the standard of English as spoken by EU pharmacists practising in Ireland. On re-reading the article it occurred to me that many of the replies that I had been waiting for at the time still have not arrived. So I decided to take a wider view of the issue. This is not unique to pharmacists. Other profession have to face the same issue. So to this end I checked the websites of the Medical Council, An Bord Altranais, the Dental Council and the Irish Society of Chartered Physiotherapists (ISCP). When it comes to non-EU citizens there does not seem to be any issue. All the sites go into the results that need to be achieved in the various English tests to be eligible. Buried fairly deep in the sites were the exceptions to the language rule. As well as some common sense exceptions there was also the EU citizen one. I decided to contact them to ask them what language skills would a foreign professional need to display before they would register them in Ireland. I specifically asked if there were any differences for EU citizens. I also wanted to know if they have had any complaints from the public about a professionals level of English.
An Bord Altranais was first to reply. An EU citizen does not have to show any competency in English. When it came to complaints they referred me to their website. The only thing I could find was the last annual report. This revealed that there had been complaints about “• Alleged insufficient knowledge of written or spoken English to carry out duties safely and effectively;” However there was no mention of how many or what happened to these complaints. All I could make out from the report is that it was decided that there was no case to answer or that the matter was still under consideration at the end of 2008.
The Medical Council sent me a copy of their guide to registration. This did not tell me any more than the web site. They also sent me a copy of the complaint statistics for 2007 & 2008. I tried to decipher these but they made a Dan Brown novel seem like easy reading. Despite reading them several times I am none the wiser.
Despite a reminder there has been no word from the Dental Council. The ISCP is not a regulatory body but they were in favour of language tests.
Although there is no language requirement for any EU health professional most of the regulatory bodies, PSI included, indicate that employers should ensure that any employees have a sufficient level of English to allow them to safely carry out their duties. So I thought I might ask some of the big employers how they dealt with this issue. Not being too ambitious I emailed the six major hospitals in the Dublin area asking them what policy do they have in place to deal with this. Again I asked them to differentiate between EU and non-EU citizens. I was slightly under-whelmed by the reply, singular. St Vincents Hospital replied that I should re-submit my request as a Freedom of Information request! Despite the now familiar reminders the other five have not responded.
So what started as an article about English language skills amongst healthcare professionals became one about the silence of the authorities and large employers. Could it be that there is an elephant in the room? Nobody wants to answer the question because they know the answer and do not want us to hear it.
I now plan to ask the PSI what guidelines they have or are planning for employers to ensure that their pharmacist employees have an acceptable level of English. Unlike many of their EU counterparts they have kicked to touch on language abilities for EU nationals. Now will they kick to touch the pharmacy owners responsibility to ensure that their staff can speak English?
I checked the Patients Charter to see if there was anything there about language. The only thing there that would relate directly to language is a right to information. Implicit in this is a right to information in your own language. I wonder if a pharmacist using a counter assistant to translate the patients symptoms and vice versa the pharmacist’s advice would meet this requirement. Sadly I have heard of just such a situation recently in Dublin.
As I write this it is Seachtain na Gaeilge. I wondered how many of us could say counsel a patient on methotrexate as Gaeilge? Maybe at last all those who got six A1s in their Leaving Cert could put their A1 in Irish to some use.
So to sum up. We are such wonderful Europeans that we are willing to risk patient safety by refusing to ensure that our healthcare professionals can speak English. The regulators pass the buck to the employers who in turn refuse to even acknowledge the issue. As for the PSI, none of the Code of Conduct, the Guidance on the Roles and Responsibilities of Superintendent and Supervising Pharmacists and the Pharmacy Practice Guidance Manual even mention the word English. The only mention of language is in relation to language issues of the patient. I suppose it is possible that the patient may have language issues if the pharmacist does not speak English. So maybe instead of seeking consultations on Codeine or the size of consulting rooms the PSI should get back to basics and issue some guidelines on ensuring that pharmacists can speak English.
It is slightly ironic from a patient point of view that they might be better off being treated by a professional from a third world country rather than from the EU zone. At least they can be assured that the doctor, pharmacist or nurse can at least speak English. This is in no way a slur on the third world but rather on the moronic way that Ireland has chosen to interpret EU legislation.

 

May

The IPJ, RIP

The post was waiting on the floor when I arrived in after the Easter break. The usual flyers, bills and must have offers. Then I happened upon the IPJ, or the Irish Pharmacy Journal to give it’s proper name. My initial thought was “It’s a bit light this month.” And sure enough only 28 pages. Then it hit me with a smack. Just over the cover picture, Vol. 88 NO.s 1, 2 and 3. January – March 2010. It was April and this was the first IPJ that I had received this year. And after 3 months all that could be mustered was 28 pages. Twelve of them were full page ads as well as two half pages. Add in the cover and this left only fourteen pages of reading. There was Cicely Roche’s page and a half on Children and the Law and Bernadette Flood’s page on “An Invisible Profession.” The rest was just a re-hash of various PSI circulars that I had seen over the previous months.
I was thinking to myself that it did not seem to be that light usually so a I did a bit of checking. Back in 2008 the IPJ was at least 28 pages every month. But by the end of 2008 it had started to come out only every second month. And now it appears that it will only be four times a year. And the question that must be asked is will we miss it?
This is the part where I take out my pipe and slippers. Way back when I first qualified in 19..cough! the IPJ and the IPU Review were compulsory reading. The IPJ was almost a social journal. It stopped short of Births and Marriages but it certainly listed the deaths. Marriages were mentioned for the lady members who underwent the compulsory name change on marriage. The wording usually went “The following names have been changed in the register (marriage certificates having been submitted.)” One friend came back from her honeymoon to see the notice of her name change in the next months journal. She took umbrage at this as she had not submitted any cert as she wished to keep her birth name. The inspector had called to the pharmacy that she was working in while she was away on the aforementioned honeymoon. On hearing of the marriage the inspector submitted the details for publication. Suffice to say that the following month an apology appeared and her name was returned to it’s original form. You could also follow the progression of your old class mates and friends just by perusing the photos and reports of the various golfing and bridge tournaments as well as the many other social events that took place.
It would appear that all this is no more. Part of this I suspect is that it is just a victim of changing times. Up to recently the PSI was part of the pharmacy scene. Albeit with certain powers. Run by pharmacists for pharmacists. Now it is definitely seen as the regulator, part of the civil service and not on the side of pharmacists any more. This is a view that the PSI itself seems to have encouraged. A lot of the old content is now available via the web. There is also many more pharmacy publications, the field being lead by this wonderful one.
So where does the IPJ go from here? Is there any real future for it? Does anybody care? I cannot see a role for it. By moving to publishing every third month it becomes less and less relevant. For advertisers it becomes a less attractive prospect. This is apparent in this years only issue so far whereby one third of all advertising in the IPJ is from just one company. Close to half of the adverts are for products or services that only available directly from hospitals, community pharmacy doesn’t even get a look in. If the adverts aren’t there will the PSI find the money for a journal at all? And even if they can find the money would they use it to produce an IPJ? Surely they could find some spare cash from their new found €6 million of income for the IPJ. Part of the lack of relevance has to be laid at their own door. On the PSI’s website it states that part of the role of the IPJ is “Providing a forum for debate about current issues and future directions in pharmacy “. The IPJ failed to have any real discussion during the dispute with the HSE in 2009. Whatever about the politics of the issue it at least merited having some debate. Not wanting to upset or disturb their Dept. Of Health overlords the IPJ just buried it’s head in the sand and buried it’s own future relevance to Irish pharmacy. The IPJ is of such importance to the PSI that it does not merit even one mention in the PSI’s service plan for 2010-2012. I feel that this says it all.
The PSI is also unique amongst the regulators of the various medical professions in Ireland in producing a journal/magazine in this glossy format. The most the others produce are quarterly newsletters which are nearly all in pdf format with no advertising. Surely there must be some form of ethical dilemma for a regulator to take advertising spend from an industry that it is part of regulating. While it does not regulate it’s advertisers directly it is involved with the IMB and other arms of the state which do. Like Caesar’s wife it should be seen to be above all of this. Perhaps they form a committee to seek consultations and then debate this matter. And then they could publish the result of their musings in the next issue of the IPJ. If there is one!

June

If you look like a duck…….

…..Then be ready to called a quack!

When you look around your pharmacy today just ask yourself a question. How many of the “medicines” on your shelves “work” on a basis of belief rather than good scientific evidence.
A few weeks ago for a joke I posted a spoof ad for a weight loss meal replacement shake on my blog. At that time I suggested using McDonald’s Milk Shakes as a meal replacement. Then right on cue Boots announced their partnership with Tony Ferguson and his meal replacement system. And frankly I think that my spoof was more nutritious. It certainly had a better taste. Then I got to thinking. This is always a dangerous thing. Just how many quack preparations are being sold in Irish pharmacies?
Weight loss products are probably one of the biggest turnover wise. They are certainly the most “in your face” if going only by the number of banner sized posters that I see in pharmacy windows. The meal replacement shakes are only part of this. There are no end of vitamin/supplement type products which claim to help you lose weight. There seems to be a new one every week. But the problem for pharmacists is how much of our credibility are we losing by promoting these products? We put ourselves forward as professional experts on medicines and yet many of us are willing to stand over and endorse quackery. In many cases the only “evidence” for the efficacy of these are the claims printed on the packaging.
It is not only the weight loss products which undermine our credibility. Homoeopathy is the other biggie. I know that it has been a long time since I was in college but if my recollection is correct we were told nothing about the memory properties of water. We were told about properly conducted clinical trials and I have yet to hear of any properly run trial which has proved any homoeopathic preparation to be of any efficacy.
The other current fad seems to be for detox regimes. These range from the harmless (and useless) detox patches to what are effectively laxatives. I have also heard of one pharmacy that has a salon attached which carries out colonic irrigation. At least the worst the detox patches can do is a contact allergy to the adhesive. Unfortunately the same cannot be said of many other alternative treatments. To date we have not had a case as bad as the Australian couple who were found guilty of the manslaughter of their 4 month old daughter. The husband, a lecturer in homoeopathy, has treated her eczema with homoeopathy rather than conventional medicine. By the time that she taken to hospital her corneas were beginning to melt as a result of infections. Sadly she died three days later.
This belief in alternative medicine is akin to a religious belief. And maybe as a society our loss of faith in the church is now being replaced by a faith in quackery. It certainly harkens back to the days when the most effective contraceptive available in Ireland was saying a Novena when your period was due.
Now I have not been party to any negotiations between the IPU and the Dept. of Health, but then neither have many us. But I can imagine the scene as the IPU try to convince the Dept to roll out a minor illness scheme. “We are the experts in dealing with minor illnesses. We know all the drugs and their appropriate use.” And then some smart ass on the other side of the table would comment “Which homoeopathic preparation would you be recommending for indigestion?” We do not lend our credibility to these products, we give it to them. It has taken pharmacists a long long time to earn this credibility and here we are spending it like sailors on a spree.
Before you start to assail me for my view do not take the above as an attack on complementary medicine. I differentiate between alternative and complementary. I have no real problems with herbal medicine for instance. There is plenty of good evidence of the medicinal properties of many herbs. There is also plenty of exaggerated claims for some herbs especially in the weight loss area. And what better place to be informed and educated about herbs then in the pharmacy. We have a wealth of information from our years spent studying pharmacognosy. The very least that we could do is to guide them away from those which can cause harm and those being sold on the basis of exaggerated claims.
So what to do? My preferred option is the one that I have taken myself. I just don’t stock them. This is easy for me as I started in a greenfield situation. When asked about it by customers I just say that I don’t stock them. Long ago I would have a discussion on why I don’t believe in them but I got tired of the responses that treated me as the odd ball because I didn’t believe that sugar pills could cure cancer or autism. Those with an established business are placed in a quandary. My preferred option in this case would be to stop recommending them. All of this pre-supposes that the pharmacist has the final say in the matter. Spare a thought here for the employee pharmacists. I have been made aware of a situation which occurred in a branch of a pharmacy chain based in the south east. The employee pharmacist in question was reprimanded because they would not recommend a detox patch to one of the companies mystery shoppers. What hope is there for ethical pharmacy in that chain?

If we want to be taken seriously and treated as professionals then we must behave like professionals. If we behave like charlatans then we can keep on quacking.

 

July

How private is private?

When I started to write this article the PSI’s guidelines for consultation areas had not been published. Now that they have been I looked at this again and found that I had to change very little.

The PSI recently called for consultations on the draft guidelines for consultation areas. Along with many others I sent a submission in. It remains to be seen if the PSI pay much heed to our submissions when the final version of the guidelines come out. And having looked at the guidelines it would appear that they have not.

One of the issues that I raised was that of timing. It would be unreasonable to expect all pharmacies to have to change their consultation areas overnight. It would only be fair to allow changes to be made at the next re-fit. I had a minor re-fit forced on me late last year due to a burst pipe. I took the opportunity to enlarge and re-shape our consultation area. I tried to imagine what the final guidelines would be as I designed the new consultation area. Unfortunately I did not have the luxury of time to wait for the PSI to have their deliberations. I would hate to have to pull out our newly painted and carpeted shop front just to keep the mandarins in Shrewsbury Road happy, never mind the expense.

Another issue which arose was that of landlord consent. Depending on the terms of individual leases it is necessary to obtain consent from the landlord for any changes to the fabric or layout of the pharmacy building. This begs the question as to what happens if a landlord for whatever reasons decides to withhold his consent to changes which would be necessary to meet the PSI’s new guidelines. Will the PSI back up the pharmacist in his/her negotiations with the landlord or will they use it as another stick with which to attack the poor pharmacist?

All of this assumes that you have the space to play around with in your pharmacy.

Recently I had a discussion with another pharmacist about consultation areas. We both had a major advantage over the PSI in this matter. We both had experience of practising in pharmacies with many different types of consultation areas. And our experiences were very similar. Most of the consultation areas go through about four different phases. Initially they are used eagerly by all staff in the pharmacy, not just the pharmacist at every suitable opportunity. Next they become unused as pharmacists discover the drawbacks and patients shy away from them. More of this anon. Then they start being used as extra storage and lastly they return to general retail use.

When I had a truly private consultation area I quickly discovered that patients did not like it. It wasn’t too hard to discover why this was so. Even when there was no physical door or barrier to the entrance patients felt trapped. Either the pharmacist stood partially of totally between them and the exit or they stood with their backs to the exit. It was very difficult to arrange the consultation in such a way so that they did not feel trapped.

However from a pharmacists point of view the privacy gave rise to the biggest problem.. In one particular consultation area that I used there was total visual privacy. So while in the area we could not be seen from the pharmacy, but neither could we see what was happening outside of the area. It was possible for a third party to stand just outside the area unseen and overhear any conservation inside. It follows that while in the consultation area I had no view or oversight of the pharmacy or OTC counter. If the PSI’s interpretation of supervision is correct then all dispensing activity and all OTC sales would have to stop while the pharmacist was advising a patient except that they have slipped in a phrase “The pharmacy owner, superintendent and supervising pharmacists must ensure the availability of adequate pharmacist personnel to fulfill (sic) all requirements outlined in the legislation.” (This would also apply to when a pharmacist is taking a toilet break but that’s a whole different article.) If the PSI’s desire for a truly private area comes to fruition then it would seem that every pharmacy would need to have a second pharmacist on duty at all times as there would be no predicting when the pharmacist would need to leave the pharmacy unsupervised so that he/she can carry out a patient consultation. This extra expense would place an intolerable burden on the smaller pharmacies.

This plays into HSE’s stated desire to see about 600 pharmacies close. Drown them with extra expense and paperwork. Twist the knife one one time in the backs of independent pharmacies. Clear the field for the chains, Irish, British, German, Dutch and what ever you’re having yourself.
Why do the PSI feel that they have to re-invent the wheel or fix what ain’t broke. It would seem that they have too much money (mine and yours) and too much time on their hands. To listen to PSI you would think that pharmacists have not been having private consultations and conversations for years in consultation areas. They may have not called it a consultation area but every pharmacy had a space where advice could be given discreetly and with confidentiality. Maybe it’s time for the PSI to get up off their backsides and spend some time in the real world of community pharmacy. When was the last time that any of the staff of the PSI actually dispensed a prescription, gave advice to a patient or even stood behind a dispensary counter. If patients do not like the set up in any pharmacy they can vote with their feet and walk out.

 

September

Where do we go from here?

Over the long and lazy summer I took some time to consider what is the future of pharmacy in Ireland. Also what can we as pharmacists do to influence it. For me, like yourselves this is more than a philosophical argument as pharmacy keeps my children fed and a roof over my head. It is clear that the cuts imposed by the HSE were going to initiate changes. But I think that changes were afoot for the last few years. The HSE cuts undoubtedly accelerated some of the changes and maybe not for the best.
Over the last few years I have seen a change from a community pharmacy with a decent front of shop to a general purpose health and beauty and photographic store with a pharmacy at the back. Indeed in some locations it is hard to tell that you were in a pharmacy at all. This is not to say that all pharmacies are following this model but enough have done so to change the public perspective. How are we supposed to portray ourselves as healthcare professionals when it seems, to the public at least that we are more concerned with false tans and photo labs. Some pharmacies I’ve seen give more floor space and prominence to their photo lab than to their dispensary.

Maybe we should look at the example of some of the drug companies. Unhappy with the payment structure in Ireland many have just stopped supplying. Their products are available as ULMs at greatly inflated prices and after much hassle on the pharmacists part. One of the reasons the action last August failed was our unwillingness to impose any hardships on our own patients. The drug companies don’t seem to any such qualms. It amazes me that some pharmacists seem to have such a low opinion of their own value as a professional that they are willing to operate the current format of the Hardship Scheme at a loss. If you are prepared to act like a doormat then don’t be surprised if the HSE/PCRS walk all over you. But at some stage you have to stand up and say “Am I getting a reasonable return for my time, effort and money?” There seems to be those in the HSE/PCRS that think that “Profit” is a dirty word. Maybe they would prefer to operate a state run pharmacy system that stayed within budget and did not make a profit. Oh wait, they tried that last summer……..

It is clear that the HSE are only paying lip service to any consultations. (In fairness, they were ignoring all representations from all parts of the health service, not just pharmacists.) None of the negotiation or industrial relation techniques previously used by the IPU had any noticeable effect. Lobbying of T.D.s no longer has any effect as many are resigned to losing their seats anyway. There also seems to be a requirement for Ministers of Health to have some kind of mental block when it comes to using the skill set pharmacists have. They see a crisis as a time to panic rather than a time of opportunity. As I have said before I have a theory that both the current minister did not receive enough lollipops from her local pharmacists while growing up or maybe had her heart broken by pharmacy students when in college. Pharmacists are seen by politicians as an easy hit. Make cuts rather than doing things more efficiently. Cut services rather than look outside traditional channels for more cost effective ways to provide the same level of service. There is a continuing failure to to recognise the savings that could be made by fully utilizing the pharmacists skill set.

Across the profession, two main actions were taken to aid survival, one positive and one negative. The negative one was staff lay-offs and cuts in services offered. Along with the Government cutbacks, we have also had to deal with the bursting of the Celtic Tiger bubble. Consumer spending is down and deflation the order of the day at least for the next two years or so. Everybody has seen their front of shop sales drop. In some cases, opening hours have been reduced and ancillary services dropped. Sadly many people, government included, never value something that they get for free. It will cut away at our accessibility but it could make the whole profession more viable. I think that from here on any new service outside of the basic package should carry a charge. It will be appreciated more and less likely to be abused. It would be very difficult to introduce new charges for add-ons that are currently free but we may need to look at this. I think that in retrospect we should consider offering these services for free a very expensive lesson.

The positive was the coming together of independents to form buying groups. Before this, buying groups were mainly the preserve of the chains, who could command purchasing policy from a single head office. Now, in return for giving up some of their independence, we get a better margin. Effectively it means passing on some of the cuts to the wholesalers and manufacturers, but it improves our bottom line and helps us survive. Also we are talking to each other a lot more now. Not in a way that would have the Competition Authority wetting themselves but by offering collegial advice and moral support.

My advice, based on our experiences to date, is to talk to your colleagues and take decisive action early. Evolution has shown that those who change first survive better even if their adaptation is not the most advantageous. You need to be able to look at your pharmacy dispassionately. The big difference from the independents’ point of view is that we now see our pharmacies primarily as businesses and as community pharmacies second. This may seem to run counter to what I have advocated above but if your pharmacy does not survive as a business then it will not survive, period. Pharmacy is undergoing a paradigm shift, in Ireland at least. Survival and future growth will be determined by an ability to change. We just haven’t figured out exactly how we have to change yet.

October

I didn’t want another rant about the PSI but…………

They just give me so much material. But before I start on this rant I must throw in a few comments about the Pharmacy Journal. In a previous article I remarked that it seems to be getting lighter with every issue. But up to this I had missed one thing which was pointed out to me by another pharmacist. There is no letters page any more. I don’t know if this is because nobody bothers to write in any more or that an editorial decision has been taken to exclude them. Either way it has the effect of making the Journal a propaganda piece. And as such it becomes less and less relevant to practising pharmacist. It is coming perilously close to being dumped with the rest of the junk mail in the re-cycling bin.

And now back to the subject of this months article/rant. It concerns Ambrose’s letter in relation to companies conducting retail pharmacy business. It is a wonderful statement of the regulations and the PSI’s interpretation of them. But like many of the Ambrose’s pronouncements it seems totally dis-connected from the real world. It is truly a laudable thing that the regulations state that every pharmacy must have a supervising and superintendent pharmacist. But what happens if our supervising/superintendent pharmacist while jogging/cycling/driving to work in their pharmacy is hit by the proverbial bus and killed. Is that pharmacy supposed to close until a meeting of the board of the company meets and appoints a new supervising/superintendent pharmacist AND notifies the PSI of the new appointment? Yes according to Ambrose’s letter. All this presumes that the advertising of the position, interview and completion of notice period in a previous employment can all happen in an instant. And woe betide us if all this happens on a weekend or bank holiday. I won’t even go into what happens to patients who have left in prescriptions the previous day for later collection or Methadone patients calling in for their daily dose. Then I thought about how I would handle this situation and I realized that I would not be dealing with this situation.

Like many of you reading this I am the superintendent and supervising pharmacist for my own company. I own the company 100% and my current wife and myself are the only directors. I will be one hit by the proverbial bus. My current wife/future widow will be one dealing with this. So in the midst of my hoped for grief she will have to go searching for a superintendent and supervising pharmacist before she even looks for an undertaker. Do all this before she sticks me in a box and pops me in the oven. It looks like that the PSI would be after her for their pound of flesh faster than a banker after a government guarantee.

This is classic bully behaviour, huff and puff and threaten but don’t actually do anything. I’d love to see them try to prosecute a widow(er) in court under these regulations. Not for the sake of the widow(er) but just to see a case hardened judge rip them apart.

It occurred to me that similar situations arise on a regular basis. Last summer in the interests of domestic harmony we had a family holiday. I secured the services of a good locum and we set off. For the next two weeks I was out of contact. Mobile phone reception was patchy at best. As an aside how did we manage in the days before mobile phones. Yes children there was such a time. So for two weeks my pharmacy was effectively without a superintendent or supervising pharmacist. So from a professional point of view what is the difference between a superintendent pharmacist dead for two weeks and the same superintendent incommunicado for 2 weeks. Either the legislation and regulations were badly drafted by somebody badly advised about the realities of real life pharmacy practice or it was deliberately drafted this way to have a go at pharmacists who would stand up to the Minister and the HSE.

If Ambrose thinks that this is unreasonable and not the intention of the regulations then all it might take is a piece of common sense, (sadly lacking it seems in the PSI) and an explanatory note covering these type of situations. It may be that Ambrose has a S.O.P for this kind of situation and if so why not publish it? Has he approached the Department of Health seeking a change in the law or regulations? Or maybe he plans to allow for the regulations to be ignored on a case by case basis. Sitting on high like the Lord of Shrewsbury dispensing his munificence to those he deems worthy. It could be that he sees monsters lurking behind every possible breach or challenge to the regulations. If you grow up in a land of monsters and train as a monster slayer it is not surprising that you treat anybody who disagrees with you as a monster. However this is not always the case. Some of them may be your allies and only become monsters because of how you treat them. A wonderful self fulfilling prophecy.

It looks like you are dammed if you die, dammed if you don’t.

Just as a follow up to a previous article I note that the Medical Council has written to Mary Harney to warn that patients are at risk of serious medical mistakes because EU workforce rules mean that doctors from the EU do not need to pass English language exams to work in this country. This is exactly the same situation as the PSI faces with pharmacists from within the EU. Wouldn’t it be nice if the PSI were to write to Minister Harney and ask her to deal with this as a matter of urgency that the IMC seems to think that it deserves.

November

So we have reached October and for the Interns and Tutors it is a case of another year over. And from all our points of view the last year has certainly been a memorable one. The old Chinese curse “May you live in interesting times” springs to mind. I had a chat with my departing Intern about her job prospects and the outlook is indeed gloomy. Once again the talk is of emigration. Mostly Australia and Canada, the UK does not get much of a look in for today’s graduates. Even though emigration is not the big deal that it was when I qualified this still saddens me. After five years of hard slog at the expense of the taxpayer they through no fault of their own they will now be lost to Ireland.
Now those of you accustomed to my scribblings will know that this is the kind of thing which gets me thinking. Just how many positions are available to the 170 graduates who will be sitting their final exams this November? Not enough it seems. The current freeze on hospital appointments is not helping. Maybe in a few years this might change but for now it just adds to the woe. But just how many new pharmacists does Ireland need every year?

So I set off to find out. My first port of call as with any pharmaceutical matters was the PSI. No don’t worry, this is not going to be another PSI rant. I’ll have plenty more of them in articles to come. I emailed them asking if they were aware of any manpower studies in relation to pharmacists. I also emailed the Department of Education as they pay for all the pharmacy courses. By return the Department replied that they did not have any studies but referred me to the HEA. They in turn referred me to Fórfas on whose website I found surveys for 2005, 2006 and 2007. At the time of writing the PSI haven’t even replied to my original email. OK so I’m allowed a little rant! I also culled some figures from the PSI’s Corporate Strategy. So they weren’t totally useless.

I started by calling these “Manpower” surveys. However Womenpower may be more accurate. As from 50% in 2005 the fairer sex have risen to 70% of the pharmacist workforce in 2007. Aside from this the workforce has increased from 2,500 in 2005 to 4,500 pharmacists on the PSI register in 2010. (Lets not forget the 500 or so Qualified Assistants who are still on the register as well.) Assuming that approximately 10% of the register is not in active practice this gives a workforce of 4,000 to 4,100. This is a massive increase in any workforce in such a short period. When you look at the age profile the numbers over 55 years of age in 2005 was 10%. This rises to 18% in 2007. So in the next 7 years (ie up to 2017) we can expect about 500 pharmacists to retire from active practice. So how are they being replaced? The surveys reported a growth rate on 10-12% p.a. in pharmacy with a replacement rate of 2.8% required. The PSI’s Corporate Strategy estimates that they will register 150 from Irish universities, 90 EU nationals and 10 from outside the EU every year. I suspect that many of the EU nationals will be Irish students currently studying pharmacy in the UK. That is 250 new pharmacists every year. A replacement rate of 5.5%. Twice the rate that Fórfas recommends. So the 500 retirements from 2007 to 2017 have already been replaced by 2009. By 2017 500 retirements will have been replaced by 2,500 new pharmacists. Even with my B in Leaving Cert maths these numbers don’t add up. So why all the pharmacy places in universities?

All of the studies mentioned above noted the pharmacist shortages which certainly existed at stages in the past. But it seems that when planning (if any such planning occurred) for university places no account was taken of EU pharmacists who now have free movement and mutual recognition of qualifications. Also no allowance was made for all the Irish students who might travel to the UK to study there. So now it would seem that we are heading for massive over supply.
The PSI have stated in their strategy that they would like to see more pharmacists per pharmacy. They have also said that they would like to see a return to a version of geographic distribution via some form of licensing. While these are laudable desires there is no mention of how this is to be paid for. I would readily have more pharmacists practising in my pharmacy if I could get away with only paying them the minimum wage. If the current over-supply continues this may yet be a practicable proposition.
The same market forces may deal with this matter at least on a short term basis. Numbers aren’t available yet but I suspect that the numbers of Irish students travelling to the UK to study pharmacy is on the wane. Those who started in the last few years will most likely finish their course but I doubt if many have started in 2010. Also the current recession / depression / double dip / “we’re all screwed anyway” will discourage pharmacists from the eastern states of the EU from travelling here.
But for now unless the PSI, Department of Education and the HEA sit down together and discuss this it looks like we will be pumping your and my taxes into training our best and brightest for export.

Just to finish on a side note. When UCC announced the start of their pharmacy course I asked a southern colleague why did Cork need a School of Pharmacy. His reply was “Sure Dublin has two, boy.” Hate mail can be sent to me via the editor!

December

The editor titled this piece “Fádo, fádo, there was a a two tier health service”

Granddad, What was it like in the old days?

The old man lowered himself gently into his favourite armchair. Barely had he got himself comfortable when in charges the terrible twins. Not that they were that terrible to him. How could anyone not like their grandchildren. It was just that he was exhausted now. He quietly cursed the minister who changed the retirement age to 70 to try and save on pensions. When he started working all those years ago he didn’t expect to live to 70, never mind be still working.
He was babysitting them today to let his son and his partner go north for some Christmas shopping. Even though the Republic had left the Eurozone, or were they kicked out, and re-launched the Punt and linked it to the Dollar most things were still cheaper up North. He had taken them to the playground in the park to try and tire them out but had only succeeded in tiring himself. So now he was hoping to get them to watch a movie that he had downloaded earlier in the day. But, no joy. What to do?
The kids came up with the answer. “Granddad. What was it like in the old days?”
“Well which old days?” he asked.
“The bad ole days when daddy was a teenager and we had a two tier health service. If you had insurance or money you got treated and if not then you waited for years,” they replied.
“Oh you mean the noughties when the country was screwed? Well sit ye down there and I’ll tell you all about it.”
As they settled down he started to revive some memories that he had long consigned to “best forgotten” part of the brain. “What you have to remember is that the country was up the creek. We were sold down the river by politicians who many believed and still believe to be the most corrupt that this country has had since it’s inception. They starved the health services of money and this in turn lead to a massive reduction in quality and quantity of services available to the public. They cut back on payments to all the professionals, doctors, dentists, pharmacists, the lot. Many community pharmacies went to the wall and closed. Many others, myself included only survived by the skin of our teeth. We had to cut back everywhere, let staff go, reduce our hours and services provided.
There was no imagination by the government in how to deal with things. They were hanging on to power by any means. But come the spring of 2011 the Supreme Court ruled that they had to hold bye-elections for the out standing seats. Even those dum dums could see what was going to happen and called a general election. They were wiped out. Even Sinn Fein got more seats than Fianna Fáil.
But then things started to look up a bit. The new government was desperate to find ways of saving money. So desperate that they looked at alternative ways of doing things in the health service. As luck would have it one pharmacist had the ear of one of the new ministers. She had provided him with a great service when he was very ill a few years previous. Even saved him a load of trouble by spotting an interaction caused by the hospital not being aware of one of his GP meds. She casually mentioned in passing some of the ways that pharmacists could do some of the things cheaper and with greater convenience. Routine ‘flu vaccinations was the first biggie. After that screening for diabetes, cardiovascular disease, basic cancers. Many of the activities that the public take for granted in their local pharmacies now. It was all ground breaking stuff in those days.
What should have been the high light for me was when an ex-minister for health was jailed for corruption. I never thought that I would see this in my lifetime. But for me the high light also came from the courts. One of the Irish chains took an action against the PSI. One of their pharmacies had been prosecuted for not keeping to one of the PSI’s self made guidelines. They went to the High Court to get a ruling on what exactly was the power of the PSI. The PSI were rightly hauled over the coals by the judge. The PSI was there to regulate not to legislate. Threatening to prosecute pharmacists if they did not adhere to their guidelines was classic bully behaviour. If they thought that the regulations needed clarification then that was the job of the legislature not the mandarins. Their inability to take the basic economics of pharmacy into account called into question the ability of the PSI to regulate the profession properly. The best part was when the Minister for Health decided to adopt the Canadian system whereby pharmacists voted on any new regulations. This in turn lead to much higher compliance and a lot of frustrated would be dictators in Ballyfermot*. This is where the PSI had to move to after it was decided that Shrewsbury Road was too valuable a property for what was essentially a bunch of pen pushers.”

By this time the twins had curled up asleep on the rug before him. He put a blanket over them and went to the kitchen to make himself a coffee. He pondered to himself. What would become of them when they grow up? Maybe once again there might be future for them in community pharmacy. He had steered their father and his daughter away from pharmacy as a career choice. Computers and the law, and they had both done well for themselves. At least they didn’t have to emigrate like many of their classmates. He only wished that his wife had lived to see them prosper. He was in no doubt that the strain caused by those years had broken her health. Just then the door bell rang. It was his son the computer whizz kid and partner back. They brought him a nice bottle of port as a thank you gift.
Later on he thought, “Right I’ll open that port now and get on the PC and have a chat about the proper good ole days with some of the guys and gals.” As he raised the first glass to his lips he tipped it skyward. “Here’s to you old girl. We didn’t do too bad with them after all.”

* The above should not be taken as a slur on Ballyfermot or anybody connected with it. I spent five and a half years working in Ballyier and it was some of the best years of my life both professionally and personally.

 

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