Irish pharmacists often provide care and advice beyond their professional remit. Dr Muiris Houston reports on an untapped medical resource.
The middle-aged woman is in deep conversation with the pharmacist. Visibly anxious, she is concerned that her youngest daughter's skin rash has not responded to an antihistamine medication prescribed by the family doctor. After some gentle probing, two key facts emerge: the medication has been given less than 24 hours to work and the woman's older son has just been admitted to a psychiatric hospital suffering from a deep depression.
Having established the principal reason for her anxiety, the pharmacist advises that the daughter continue with the medication for another couple of days in order to give it a chance to take effect.
Seamus Ruane is the pharmacist/ proprietor of the Mervue Pharmacy on the outskirts of Galway city. One of Galway's more established suburbs, Mervue is a discrete community near the large ThermoKing plant to the east of the city. Seamus has run the pharmacy here for five years, having purchased it from its previous owner.
The dispensary assistant at Mervue Pharmacy, Deirdre McSweeney, has worked in the business for 18 years and, like the rest of the staff of six, she is on first-name terms with most of the customers. A 1990 graduate of Trinity College Dublin - which was until recently the only pharmacy degree course available in Ireland - Seamus worked at a hospital and in other community pharmacies before buying his own business in Mervue. He is committed to developing the role of the pharmacist as part of an extended network of primary health care services.
"I would love to get involved in the treatment of minor ailments and I have been trained in the use of brief interventions for those giving up smoking or wishing to start a diet," he says. "The community pharmacy remains an untapped resource for primary health care."
The Government Primary Health Strategy, published in November 2001, places community pharmacists within a primary care network, which it is envisaged will serve two to four primary care teams in each area. And while the strategy does not go into the specifics of how a pharmacist's role might develop, individuals such as Seamus Ruane are clear on how they can make a difference. In terms of teamwork, he sees a role for pharmacists working closely with GPs and nurses in order to give prescribing advice.
"A pharmacist could help doctors with prescribing analysis and contribute to the development of prescribing policies which would maximise the use of cost-effective treatments," he says. As well as their current role in dispensing methadone to recovering drug addicts, pharmacists could help to set up needle exchange programmes. Nor is there any reason why they could not begin to offer home visits, which would help certain patients improve their understanding of why they were taking certain drugs, but would also help improve compliance and identify unnecessary medication use. In one British study, pharmacists helped to identify unnecessary use of medicines among a group of patients which led to an 18 per cent reduction in drug costs.
Pharmacists could also develop the concept of "near-patient testing". Many people taking the anti-clotting medication, warfarin, those with diabetes and others with chronic disease, must attend hospital for regular blood tests. As technology simplifies however, it is now possible to perform many of these regular checks in a pharmacy or surgery setting. Not alone would this take the pressure off hospital services, but it would be of huge practical benefit to older people and people with a disability.
Health promotion, whereby pharmacists add their advice and input to mothers concerned about MMR or other childhood vaccinations, is another area ripe for development. Promoting flu vaccination, use of folic acid in pregnancy, dietary intervention and smoking cessation are just some of the health promotion activities to which pharmacists could also contribute.
Last autumn, the first national primary health care conference heard an address from Dr Jim Livingstone, director of Primary Care at the Department of Health, Social Services and Public Safety in Northern Ireland, It was clear to those listening that he intended to place an emphasis on expanding the role of community pharmacists in the North.
"With one and a half million interactions per month between pharmacists and the community, we will be planning a great emphasis on the ready access which pharmacies offer to local communities," he said. It is an approach which pharmacists in the Republic would welcome. However, relationships between the State and the Irish Pharmaceutical Union (IPU) are somewhat strained at present. Currently, pharmacists are under the Competition Authority's microscope because of deregulation issues. And while the Department of Health appears committed on paper to developing the pro-active professional role of pharmacists, others in Government seem more interested in seeing through a complete deregulation of the sector rather than focusing on the opportunities the present system offers to develop health care in the community.
Richard Collis, president of the IPU, says that "pharmacists must seriously question the attitude of the Department of Health. Clause 9 of our 1996 contract emphasises our professional role and an interaction with patients. We need to be given the space to act professionally, but nothing has developed despite the contractual commitment."
He offers a recent anecdote from his own north Dublin pharmacy to illustrate the potential for pharmacists to interact with patients. "The first person to enter the shop at 8.40 one morning was a woman taking her six-year-old son to school. She was looking for a bandage for his wrist which he had hurt the previous evening. However, when I looked at the child's arm it was extremely swollen so I advised her to bring him to the accident and emergency department at Temple Street Children's Hospital. She dropped in two days later to tell me that he had been treated for a badly fractured wrist."
Collis says that his till does not ring for such encounters, yet it is the type of interaction for which pharmacists would like more recognition.
What about the argument that pharmacists have a very high mark up in their products and that the development of chain pharmacies will reduce costs across the sector? "The average net profit of pharmacies is 10 per cent which is by no means excessive in business terms," he says.
Both Richard Collis and Seamus Ruane are scathing of the type of service which they see as typical of the multinational chains. "It will change the focus of pharmacy. The chains are essentially a volume driven industry where the cost base is hit hard. They reduce the number of professional employees, so there is less opportunity to offer health advice and less interaction with the customer," Collis says. "The Republic has the second highest ratio of pharmacy to population for people over 65 years in Europe, which ensures we remain patient focused," Ruane argues.
Meanwhile, back at the shop front in Galway, most customers bypass the beauty and photographic products and head straight to the main counter. The computerised prescription management system is the nerve centre of the operation. One customer cannot remember the name of an anti-inflammatory medication she took about a year ago. A quick check on the computer - which contains details of all scripts filled for this woman going back to 1995 - and the product is identified.
It is also helpful when there appears to be an anomaly in a script written by a local GP. A phone call to his surgery confirms that a slip of the pen had inadvertently changed the dose of a cardiac drug. The prescription will be amended by the GP later in the day.
Pharmacists may have moved a long way from the routine use of a mortar and pestle with which to make up their own concoctions but it seems that they do not want to lose the age-old practice ofcustomers taking them into their medical confidence and maintaining a professional relationship with the community.