Uncharted territory for Irish pharmacists

An expert taskforce has laid the groundwork for the expansion of pharmacy services. Pat Kelly examines the practicalities for pharmacists, doctors, and for patient care

In August 2024, the Department of Health released the Final Report from the Expert Taskforce to Support the Expansion of the Role of Pharmacy. It contained a range of recommendations aimed at improving access to care in “the evolving healthcare landscape”.

The expert taskforce was established in 2023. It was given the remit of identifying and supporting the expansion of the role of pharmacists. The final report maps out a pathway to implementing pharmacist prescribing, initially within the common conditions service.

Over time, pharmacists should be enabled to exercise independent, autonomous prescriptive authority within their individual scope of practice and competence, according to the report.

The report cites studies on pharmacist prescribing models to manage minor ailments in the UK, US, Canada, and New Zealand, including systematic reviews and pilot projects in these jurisdictions.

The report authors say the recommendations are supported by national and international experience and are founded in academic research and practice, as well as submissions from a public consultation.

A research sub-committee was assembled in February 2024, chaired by a taskforce member, and includes participants appointed from research and practice settings. Its purpose is to develop a research agenda to inform and enhance implementation, and evaluate the effectiveness of the recommendations.

At almost 100 pages long, the final report outlines the operational, strategic, and regulatory frameworks necessary to achieve an expanded role for pharmacists.

The Department emphasises that full pharmacist prescribing authority, and increased pharmacist autonomy, are intended to enhance patient care, optimise healthcare resources, and support the development of Ireland’s healthcare system.

The final report follows an interim report that recommended pharmacists be enabled to extend six-month prescriptions by up to  six months, where safe and appropriate. The Minister for Health subsequently accepted the proposals and implemented the scheme.

Debate

The taskforce recommendations have been the subject of debate. Some within the medical profession have expressed concerns, which they say are based on patient safety.

The IMO informed the Medical Independent (MI) it has “serious concerns” about the proposals. “Doctors and pharmacists have a long history of collaboration, each working together in their different roles,” said its spokesperson. “However, in response to the challenges facing healthcare systems today – of an ageing population, increased rates of chronic disease, economic constraints and a shortage of doctors – many jurisdictions have sought to expand the role of pharmacists into activities normally carried out by doctors.

“The IMO is concerned that the transfer of tasks from doctors to pharmacists is unsupported by the evidence and has implications for patient safety, quality of care, healthcare sustainability, and fragmentation of care.”

One of the rationales for the proposals was to reduce pressure on general practice. However, the IMO sees this prospect as creating more problems than it solves. “The implication that an increased role for pharmacy in prescribing will help reduce demand on general practice shows a profound misunderstanding of the importance of continuity of care in general practice and risks further fragmentation of care,” according to the Organisation.

The IMO said international evidence shows the importance of continuity of care. It stated that the new proposals would damage this chain of patient care. “Many conditions can deteriorate significantly over time and prescriptions are issued by a medical practitioner for a limited time to allow for review,” said the IMO spokesperson.

“In addition, prescribed medicines may cause adverse reactions, interact with other pharmaceutical products or doses may need to be adjusted, depending on the individual. All of these are issues which are addressed during the review.”

The IMO also stressed the importance of GP-patient relationships: “It is often during these interactions that items of care such as opportunistic screening take place and afford opportunity to discuss lifestyle and disease prevention. Time-intensive consultations for complex illness may not always afford the same opportunities.”

The Irish College of GPs was contacted but declined to comment on the proposals.

Capacity

The Irish Pharmacy Union (IPU) welcomed the taskforce report, but expressed concerns about funding and capacity.  

“A critical pillar supporting the advancement of pharmaceutical care services in Ireland is the importance placed on the strategic allocation and utilisation of human resources,” the IPU informed MI. “However, the current landscape reveals a significant deficiency in cohesive workforce planning, hindering the development of an integrated pharmacy care model.”

An integrated pharmacy care model would greatly assist in workforce planning, the IPU argues, and should be led by a Chief Pharmaceutical Officer (CPO) to drive policies and planning. CPOs are already in place in Northern Ireland, England, Wales, and Scotland. “Strategic workforce planning, led by a CPO, is vital for ensuring continuity and uptake by the profession, addressing skill gaps, enabling and enhancing access to pharmacy education, encouraging professional development, and maintaining appropriate staffing levels,” stated the IPU.

The Irish Institute of Pharmacy (IIOP) delivers a continuing professional development system for pharmacists in Ireland and helps to develop pharmacy practice in line with international practice and “evolving healthcare needs”. As acknowledged by the Department of Health, educational training courses underpinned by legislative and regulatory authority will be required for pharmacists.

As the recommendations are implemented, the IIOP – as part of the Pharmaceutical Society of Ireland (PSI) – will be instrumental in supporting pharmacists through the transition. “Our role is to support PSI, DoH, HSE and the pharmacy profession by providing training that enables pharmacists to engage in the services associated with implementation of taskforce recommendations,” the Institute informed MI.

“The IIOP website, resource hub and training programmes provide accessible, quality-assured, contemporaneous training and sources of information for all pharmacists. Last August, we provided webinars, workshops and information through the IIOP resource hub to support pharmacists in relation to the prescription extension service. We anticipate that we will provide similar types of resources to support the common conditions service.”

The taskforce’s final report provides examples of how common conditions services – also known as ‘minor ailment’ or ‘common ailment’ schemes – work in other jurisdictions by enabling pharmacists to treat self-limiting conditions. According to the Department, this will release capacity in other areas of the health service and improve equity of access to care.

The final report cites policy evidence from other countries to show that pharmacist prescribing for common ailments resulted in clinical improvements. However, the IMO has serious reservations around the introduction of pharmacist prescribing, which it describes as a “quality of care” issue.

In regard to plans for pharmacists to directly supply the contraceptive pill following a structured consultation, the IMO said: “Pharmacy prescribing of oral contraceptives has been introduced largely to support ease of access, however, the progesterone-only pill has been found to be less effective than other long-acting forms of contraception at reducing unplanned [pregnancies], and studies also show that women are more likely to choose this form of contraception if they receive comprehensive information from their GP.

“Furthermore, sexual health is not just about contraception and preventing unwanted pregnancies. Access to contraception should form part of a comprehensive women’s sexual health programme in general practice that also includes advice on STIs, fertility, and pre-conception. The assessment and consultation with the GP provide an invaluable opportunity to check in on particularly vulnerable patients….”

‘Conflict of interest’

However, the IMO went further and suggested a potential conflict of interest issue in terms of pharmacist prescribing powers. “Patients and the State have always been well served by the separation of the prescriber (the doctor) and the dispenser (the pharmacist) role, as a clear conflict of interest can arise when a healthcare professional incurs a financial gain from the medicine they prescribe,” the IMO stated. “Legislators and regulators must be compelled to recognise that a clear conflict of interest arises when a pharmacist takes on an expanded prescribing role, particularly given the growing number of retail pharmacy chains and the vertical integration of pharmaceutical wholesale distribution and pharmacy retail. 

“Other areas of concern are ‘linked sales’ policies, which link the purchase of one pharmaceutical product to other pharmaceutical products which may or may not be necessary,” the IMO continued. “Pharmacists frequently stock and sell vitamin supplements, homeopathic remedies and other products of limited or no proven therapeutic value. Recently, doctors have witnessed a considerable market drive by pharmacists to sell near-patient testing kits, which present a considerable risk of incorrect diagnosis, over-diagnosis, as well as under-diagnosis. Pharmacists also offer services such as 24-hour ambulatory blood pressure monitoring, ECGs, with no context in which to interpret the data nor expertise to treat it.”

The Organisation reiterated the importance of the GP-patient relationship. “International evidence shows that patient-focused continuity of care in general practice is key to improved patient outcomes, reduced inequalities in health, and long-term cost effectiveness. Continuity of care is also an essential part of chronic disease management. Many conditions can deteriorate significantly over time and prescriptions are issued by a medical practitioner for a limited time to allow for review.”

The IPU, in contrast, was positive about the recommendations, stating that it looked forward “to working with all stakeholders to support this important modernisation of Ireland’s healthcare system for the benefit of the population”. However, it continues to express concern about investment in the sector. “The recommendations outlined in the report support the vision of Sláintecare to expand community-based care to bring care closer to home and to ensure equity of access to healthcare based on clinical need and not ability to pay. Successful implementation of the taskforce recommendations requires a sustainable pharmacy model, and multi-annual investment in pharmacy services is a key element to that.”

Supports

On one issue, both the IMO and IPU are in agreement – each of their sectors requires better supports from Government. “Currently, there is a capacity issue in general practice and further supports are needed,” the IMO stated. “However, the diversion of care from GPs to pharmacists risks further fragmentation of care, increased medicalisation and consequently, workload for GPs.” 

The IMO was also keen to point out that it is not fundamentally against all pharmacist prescribing. “…the IMO recognises that there may be value to patients and the State in allowing pharmacists to extend prescriptions in certain emergency situations, and in allowing GMS patients to access certain OTC [over the counter] drugs without prescription which are currently available to private patients”, it added.

The doctors’ union concluded by advocating for “non-commercial/non-retail pharmacists to enhance prescribing safety, either as part of the practice team or at the request of the GP as per the 2019 GP agreement between the IMO, the Department of Health and the HSE”.