Government and pharmacists face off in Ireland

August 10, 2009 – 8:45 am by Joshua Slatko

As the debate over government involvement in healthcare builds in the United States, a battle between pharmacists and the government health authority in the Republic of Ireland over the last several weeks is offering policymakers a real-world lesson in the challenges of public administration of healthcare.

The troubles began June 18, when Ireland’s minister for health, Mary Harney, announced significant reductions on payments to pharmacists to reduce the cost to taxpayers of drugs and medicines dispensed under a series of community drug programs – the GMS (medical card), the Drug Payment Scheme, and the Long Term Illness Scheme – under which the costs of drugs are partially or totally borne by the Irish taxpayer.

“The cost of the drugs and medicines under these schemes – including ingredient costs, payment for wholesale delivery and pharmacy dispensing fees, and retail mark-ups – has doubled since 2002 and totaled over €1.68 billion ($2.8 billion) in 2008,” Ms. Harney said in her announcement of the changes. “The rapid escalation in cost must be curtailed.”

Not surprisingly, many Irish pharmacists were outraged. “These cuts announced today amount to a 36% reduction in the current level of payments to pharmacists,” said Liz Hoctor, president of the Irish Pharmacy Union, a representative body for 1,900 community pharmacists in Ireland. “These massive cuts are utterly disproportionate and totally unsustainable. These cuts compromise patient services, and up to 5,000 jobs in pharmacies could be lost as a direct result of this government decision.”

According to Ms. Hoctor, the IPU had presented an alternative strategy to the government in March.

Liz Hoctor of the Irish Pharmacy Union

“We recognize the seriousness of the country’s economic situation and back in March made proposals to the Minister which would save the State €83 million ($138.5 million),” she says. “Our proposals included enabling pharmacists to offer patients the choice of a cheaper generic medicine where it is safe to do so and the acceptance of an 8% cut in pharmacy fees, which is in line with cuts imposed on all other healthcare professionals. However, our proposals, which are practical and reasonable, were ignored by the Minister, and instead a 34% cut in payments was announced.”

The government duly enacted Ms. Harney’s changes July 1. At that point, the pharmacists moved from words to actions. A large proportion of pharmacies – the IPU claimed more than 1,100 out of just over 1,500, while other published reports put the number at closer to 700 – wrote to Ireland’s Health Service Executive giving the legally required 30 days notice of their intention to discontinue providing services for the community drugs schemes. Thus, somewhere between half and two-thirds of all pharmacies across the country would stop dispensing medicines on behalf of the HSE under the Medical Card Scheme and the Drug Payment Scheme effective August 1.

This presented the Health Service Executive with a serious problem. Under Ireland’s Drug Payment Scheme, residents of the country need only pay a maximum of €100 ($167) each month for approved prescribed drugs for use by themselves and their families. Every resident of the country is eligible for this program; hence, the refusal of pharmacists to provide services under it would affect the availability of prescription drugs to everyone in Ireland. With half the country’s pharmacists about to refuse to honor its payment scheme, the Health Service Executive was forced to work up a contingency plan so patients would still have access to the prescription drugs they needed. The organization’s idea: set up HSE-operated emergency pharmacies. A plan for opening twelve such pharmacies, with additional locations to be added if necessary, was announced by HSE July 18.

HSE’s leaders were less than sanguine about their hopes of covering all the cracks, though.

“It will not be possible to replace every pharmacy which withdraws service on a like for like basis so patients and clients may have to travel further than normal to have their prescription filled,” said Kate Mulvenna, HSE’s chief pharmacist. “We would encourage family, friends, and neighbors to assist vulnerable people who may have transport difficulties to secure their medication.”

The pharmacists themselves put the problem a little differently. July 27, Bernard Duggan, chairman of the Employee Pharmacists’ Committee of the Irish Pharmacy Union, pointed out what he called the three key weaknesses of HSE’s plans.

“(First), there is not enough detail being given by the HSE,” Mr. Duggan said. “With only four days to go before pharmacists withdraw services, patients have still not been provided with concrete information on exactly where, when, and from whom they can obtain their medication.

“(Second), too much is being expected of those pharmacists who aren’t withdrawing from the schemes….no account is being taken of the busy workload these pharmacists are already dealing with or if they have the capacity to deal with extra demand.

“(Third), there may be shortages of medicines in these pharmacies due to the unprecedented increase in demand. There are over 5,500 different items which have been approved for supply to patients under the medical card and community drug schemes. It is impractical for each community pharmacy to stock all of these items. They, therefore, stock the range of medicines that meet the needs of their own patients. The HSE contingency plan does not account for the fact that it is impossible for any community pharmacy to stock all the approved 5,500 prescription items; timely access to medicines by patients may therefore be disrupted.”

The next day, July 28, HSE published a list of pharmacies that would continue to provide services under the community drug schemes after August 1. Again, the IPU quickly struck back, claiming the list was filled with inaccuracies.

“It is clear the list published in today’s papers is a smokescreen and confirms the union’s view that the HSE has no workable contingency plan,” Ms. Hoctor said. “In accordance with our information the list totally overstates the number of pharmacies who are likely to continue providing services from August next. The number of pharmacies appears to be more of the order of 400 rather than the 800 odd claimed by the HSE.”

This began a spat between the two organizations over how many pharmacists had actually withdrawn from the drug schemes.

“It is most unfortunate that the IPU continues to misrepresent the facts in relation to the numbers of pharmacies that have terminated their agreements,” said Laverne McGuinness, national director of HSE’s Primary, Continuing, and Community Care. “The IPU has no access to our records of the number of pharmacies who have terminated their contracts. It therefore has no accurate information about who has terminated their contact and who has not, other than anecdotal information and hearsay. The IPU is deliberately using inaccurate information to create concern and worry in the minds of patients and clients. It is remarkable for a professional body to behave like this.”

But according to IPU leaders, the list contained the names of pharmacies for which HSE chose not to interpret the pharmacists’ letters of termination as giving the required notice. The IPU head office, the organization’s leaders claimed, had been inundated with calls from angry pharmacists whose names were on HSE’s list despite the fact that they have given notice of their intention to withdraw. In response to this, the IPU published on its Website a list of more than 1,100 pharmacies who had informed the organization that they were withdrawing from the HSE drug schemes.

The two groups were still sniping away up to the deadline. On the evening of July 31, HSE claimed that 200 pharmacies had withdrawn their termination notices and announced that more than 1,000 pharmacies would continue to provide services through the community drug scheme after August 1. The IPU leadership fired back by calling HSE’s contingency planning totally inadequate.

“The Minister (for Health) assured the Dail (Irish parliament) that there would be a workable contingency plan which would ensure that all patients have access to the medicine they need including those who cannot afford them,” Ms. Hoctor said. “It is clear that the HSE has failed in this regard, and it is now incumbent on them to admit that there are areas of this country without adequate pharmacy cover. The HSE and the Minister should recognize this dangerous situation immediately as ultimately responsibility for patients and their care rests with the Minister.â€�

Even after August 1 had come and gone and the HSE contingency plan had gone into effect, the two groups could not agree on what was happening. IPU leaders claimed that the contingency plans were failing dismally and that widespread shortages and delays had been experienced by patients using the special HSE dispensary services. The organization cited stories of inaccuracies in prescription-filling as well.

“One pharmacist in Kerry who checked the prescriptions dispensed to 11 of his patients by the HSE dispensary said eight of them had been filled incorrectly,” Ms. Hoctor said. “Quite rightly he is horrified at the standard of service being given by the HSE and has real concerns for the safety of his patients the longer this service continues.”

August 4, the HSE claimed that its temporary dispensing facilities had been busy but manageable over the course of the day. And HSE’s leaders placed the onus for any inconveniences experienced squarely on the pharmacists.

“In general people living in urban centers had no problem getting medication,” said Patrick Burke, head of the HSE’s Primary Care Reimbursement Scheme. “Unfortunately the most vulnerable people in small isolated communities are being targeted by a minority of pharmacists who were causing undue worry to their own patients and clients in a concerted campaign in an attempt to force a Government decision to be reversed. There is no getting away from the fact that the responsibility for the inconvenience being suffered by patients and clients rests completely with a small minority of pharmacists. Nobody else. This action is about money. It has nothing to do with patient care.”

Sometimes it seemed as if HSE and IPU were living in two different countries.

“Pharmacies which are continuing to dispense are coming under unsustainable pressure,” said John Corr, chairman of IPU’s contractors committee, also on August 4. “Prescriptions are taking eight hours to fill, people are being told to come back tomorrow, the HSE’s own emergency pharmacies do not have a lot of common medicines in stock. Another aspect we are concerned about is the fact that the emergency dispensaries are refusing to fill prescriptions for patients from certain areas. For example, patients from Westport have been refused service by the HSE dispensary in Castlebar. We have similar reports of people in Kerry and Donegal being refused service. They are being informed that they should go to a particular pharmacy. But more often than not that pharmacy is not open or is no longer dispensing under the community drug schemes. This is down to the misinformation and ineptitude of the HSE. The HSE needs to wake up and deal with this unholy mess which is entirely of Minister Harney’s own making.”

The two organizations continued to fire away at each other, day after day, with IPU criticizing alleged failures of the contingency plan and HSE attacking pharmacists who were accused of refusing service to patients even though they were still under contract in the community drug schemes. HSE even claimed that employees of its temporary pharmacies were being threatened and verbally abused, a claim which IPU emphatically denied. Finally, on August 6, Ms. Harney, the Minister of Health, acknowledged the situation publicly with a statement.

“In any commercial or industrial dispute in the health sector, patients must come first,” Ms. Harney said. “When there is a dispute over money, as is the case now, services to patients must continue safely. This has been the norm in the health sector and has been properly followed in almost all disputes.

“The situation now is that, overall, medicines continue to be provided to the patients of the country as a whole. But I am very concerned to hear reports of patients being inconvenienced and facing unfortunate and avoidable delays in the supply of their medicines, due to the withdrawal of services by pharmacists.”

Minister for Health Mary Harney

There would be no compromise with the pharmacists, Ms. Harney made clear.

“The new payment rates are now set in law,” she said. “They have been in effect since 1 July. It is done. There will be no policy change, no change in the law to change the payment rates now.”

In response to this, Ms. Hoctor offered a peace proposal.

“My members are telling me that in the present emergency and in the interests of patient safety they may resume normal services, if the Minister were to agree to the appointment of an independent third party to (1) review and establish the impact of the proposed cuts on the sector during this calendar year and (2) before the next budget to assess, in the light of that information, what would be a reasonable level of savings that the HSE could expect the sector to contribute next year in the context of the current economic crisis and the need to maintain patient services and jobs,” she said.

This proposal, though, was refused by Ms. Harney. “The issue is not one for mediation,” she said. “It is not possible to mediate law.”

And HSE’s claws are clearly out. According to published reports, August 6 the agency was granted an ex-parte High Court injunction against 35 pharmacists who had withdrawn their dispensing services from the community drugs schemes. HSE has also warned pharmacists that any who still have agreements with the agency but refuse to provide contracted services will be targeted through the courts.

“We are writing to those who are not meeting these fundamental obligations,” Mr. Burke said. “If we do not receive a satisfactory response we will have no other option than to seek to enforce our legal rights on behalf of taxpayers through the courts. We will also be seeking all costs associated with this remedy. While this is not an avenue we want to pursue, we have responsibilities to the public to ensure that they can get access to their medication.”

IPU, though, has found an ally in its criticism of HSE’s contingency planning. August 7, Age Action Ireland called on HSE to review its contingency plans for the dispensing of medication under the community drugs schemes, in order to ensure that older people do not have to travel long distances or face lengthy delays to have their prescriptions filled.

“It is not acceptable or sustainable that older people should face such stress and hardship to get their medication,� Age Action spokesman Eamon Timmins said. “Traveling long distances and having to queue for hours is difficult for anyone, but it puts huge stress on older people who may not drive or have access to public transport, and who may be ill and coming from their GP’s surgery with their prescription.�

The conflict has taken on a political dimension. James Reilly, the health spokesman for Fine Gael, Ireland’s second-largest political party, has warned Ms. Harney that her decision to refuse to open negotiations on the pharmacists’ dispute will only prolong the crisis and inflict more suffering on patients.

“This is literally a prescription for disaster,” Mr. Reilly says. “Minister Harney’s refusal to even allow talks through a mediator between the Department of Health and the IPU means the dispute will drag on even longer.

“At the same time, the IPU must appreciate the genuine suffering that their action is causing. We have open warfare. Patients are caught up in the chaos and mayhem of this dispute, and innocent victims are in the crossfire.

“Whatever happens, we need action. Either Minister Harney must try to find a resolution, or Taoiseach Brian Cowen must intervene personally. Because the longer this dispute goes on the more likely there is to be a tragedy.�

The battle goes on.

Tags: healthcare reform, Ireland, pharmacies