Prostate Cancer - Irish Pharmacy Union [PDF]

IRELAND’S OFFICIAL PHARMACY PUBLICATION

OCTOBER 2017

IPU Pre-Budget Submission

Prostate Cancer

Election time for IPU Committees HEALTHMAIL | COMMUNICATING TO PATIENTS | SHORT-TERM ABSENCES

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OCTOBER 2017

07 A Note from the Editor

IPU News

The latest news and events from Butterfield House 08 Dates for your Diary 08 Pharmacy in the Media 09 Health Service Capacity Review

The IPU Review is published monthly and circulated to Irish pharmacists. The views expressed by contributors are not those of the IPU nor is responsibility accepted for claims in articles or advertisements.

10 IPU Business Academy

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11 IPU Training Programme Autumn 2017 11 IPU supports Pieta House

Subscription: €95 (Ireland North & South) and €140 (including postage overseas). Publisher: Irish Pharmacy Union (IPU Services Ltd), Butterfield House, Butterfield Avenue, Rathfarnham, Dublin 14, D14 E126 Tel: (01) 493 6401 Fax: (01) 493 6626 Email: [email protected] Website: www.ipu.ie Editor: Jack Shanahan MPSI Editorial Associates: Aoibheann Ní Shúilleabháin, Jim Curran and Ciara Browne Advertising: Aoibheann Ní Shúilleabháin Email: [email protected] Tel: (01) 493 6401 ©2017 Copyright: All Rights Reserved, Irish Pharmacy Union. Printed by Ryson Colour Printers Ltd. IPU Review is a Registered Trademark of the Irish Pharmacy Union.

Features

12 Election time for IPU Committees

Representatives from the national committees share their experience in advance of this month’s Regional AGMs

16 IPU Pre-Budget Submission

A summary of the key issues addressed in the IPU’s Pre-Budget Submission 2018

22 Update from the National Screening Service

32

Update on BreastCheck and BowelScreen national screening programmes

26 S.T.E.P.S. to Effectively Communicating New Reimbursement Restrictions to Patients 32 Healthmail – Using Secure Clinical Email IPUREVIEW OCTOBER 2017

26 3

Growing Together

The trade mark Actavis is used under licence by Teva Pharmaceuticals Europe B.V.

Same great Team..... just a new name!

Padraic O’Brien

Louise Mooney

Damien McCormack

Richard Doherty

David Lane

Martina Sweeney

Gregg Farrell

John MacHale

Further information is available on request from Actavis Ireland Ltd, a subsidiary of Accord Healthcare Ltd Euro House I Euro Business Park I Little Island I Cork I T45 K857 I Ireland 021-461 9040 Date of Preparation: July 2017 NA-131-01

34 Osteoporosis: What you need to know

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38 CPD: Prostate Cancer 44 High Tech Medicines Update: Wakix Film-coated Tablets 46 View from the Dispensary

Where have all the young pharmacists gone?

48 Medicines and Beyond – The Soul of Pharmacy

News

An overview of the 77th Annual World Congress of Pharmacy and Pharmaceutical Sciences

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52 For whom the tills toll

Darren Kelly advises on preparing for the ‘silly’ season

56 Managing Short-term Absences 58 Pensions – here we go again

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62 Studies

56 IPUREVIEW OCTOBER 2017

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Irish Chemists’ Golfing Society News 64 Pfizer Healthy Town 2017 65 Pharmacies recognised for their commitment to the future health of their customers with ‘Crystal Clear’ Award 66 Lynch’s Pharmacy launches Telemedicine service 67 A new era for Kiely’s as they re-brand second pharmacy to CarePlus 67 Minister Harris launches HPV vaccination campaign 68 Irish Cancer Society to provide Urgent Medical Need Card to cancer patients 68 Safeguarding future medicine supplies post-Brexit 69 Medicines for Ireland warns of significant risk to patients arising from Brexit 70 HPRA publishes 2016 Annual Report 70 Accord’s focus on outstanding customer service continues with the launch of its telemarketing initiative 71 Majority of people with dementia struggling to eat properly at mealtimes 72 Healthcare company increases Clonmel investment with new €2 million warehouse facility 72 Pfizer launches new adherence app for Neuropathic Pain 73 Fleming Medical’s celebrates its 30th Birthday 73 Dovonex® Psoriasis Ointment online training course 74 75

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A NOTE FROM THE EDITOR Jack Shanahan MPSI

Moving goalposts – time for a new pharmacy contract It would be fair to say that a shiver went up my spine when I read that the HSE had contracted some consultancy to review pharmacy fees. The way the contract is structured, with little or no input from community pharmacy, is extraordinary.

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f ever the wording of a contract pre-determined its outcome, this must be the prize-winner. In an era when the people making these decisions are having their FEMPI cuts unwound, I find this egregious in the extreme. They are conflating the extraordinary costs of new drugs with the delivery of a successful pharmacy service. Community pharmacy has had a horrendous time since 2008. Not only have we had the direct cuts of both markup and fees, we have also seen a complete contraction of any purchase margins. The sector has been sucked dry. It is clear that many pharmacies are struggling financially. The changes in the wholesaler market are staggering. We only have two mainline suppliers, one of whom decided to throw in their lot with a global giant. When I started in pharmacy, there were, if I recollect correctly, at least six wholesalers. Of course, consolidation or contraction of choice is not simply the preserve of the distributors. We now live in a time where half of the pharmacies in Ireland are parts of chains or groups. In my view, this is not a positive sign of a healthy pharmacy economy. The requirement to consolidate, with the associated benefits, is now a business imperative for many pharmacies. In this context, a one-sided narrowly

focused review of fees is both unreasonable and profoundly unilateral. While we are all familiar with the definition of a cynic as one who knows the price of everything and the value of nothing, the last few decades have shown that community pharmacy has become an enormously complicated profession. While some prescriptions are still straightforward, there are a growing number of patients, and prescriptions, with issues that transcend the definition of dispensing. Every day, we can have individual patients that take up hours of professional input. It is another version of the 80/20 rule, where 20% of the prescriptions take up 80% of our time. I am not complaining; this is my job. The issue is that these patient needs must be recognised. As the population ages, and polypharmacy increasingly becomes the norm, we have a host of medication challenges. Community pharmacy is about providing a quality medicine service to the public. Encapsulated within this are all the issues of ethics, safety, supply chain management, administration, legalities and so on. A major concern is the risk that the key components of pharmacy are getting lost, or marginalised, in the drive to deliver new services. We are in the middle of the flu vaccination season. Community pharmacy has shown that it can successfully

deliver this lifesaving service in an efficient and effective manner. Yet many pharmacies are not providing this service. In my view, the major barrier to adoption is the actual cost of provision. Many pharmacies evaluating the service see it is a cost, both financial and administrative, that they cannot rationalise. If the State really sees community pharmacy as a part of a public health policy, they must resource it. The training and the adrenaline pens must be provided as an integral part of the solution. This, of course, goes back to the urgent requirement for a new pharmacy contract, one that reflects the real world; one that pays for blister packing for those that need it, and not simply for medical card holders that must call weekly. Community pharmacy is a key component of the nation’s health. The last thing we need to see is a collapsing of the wafer-thin margins that are sustaining this vital service. Thus, a weariness crept over me as I faced into another battle with the dark forces. Placing my regular faxed monthly order for Kalydeco, I was met with a resounding silence. And no delivery. Of course, the problem with a non-reply is that it doesn’t alert you. Typically, you only realise things have gone wrong when you reach for a product that isn’t there. A few days later, the phone rings from Germany. Vertex is calling.

They tell me that I cannot order Kalydeco unless I have a patient specific authorisation number. Muttering vague curses of an ancient kind, I reach again for circular 019/17 from the PCRS. It specifically states that approval is only an issue for new patients. The patient I am dealing with was approved way back in 2013. Once again, the goalposts have been moved by the PCRS, without a simple consideration for the patient. In this case, the person was lucky enough to order the medication in time, and had buffer stock. Is it not simply reasonable to expect that the HSE will actually do what they say? Yet again, another reason to have a clear pharmacy contract.

If you have any comments, queries or issues to raise, send your “Letters to the Editor” by email to [email protected].

IPUREVIEW OCTOBER 2017

7

Pharmacy in the Media

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BE N OV E M

Ahead of children returning to school, we issued a press release advising parents and guardians to ask their pharmacist about the best ways to treat head lice. IPU Executive Committee member Caitriona O’Riordan advised that it is important to seek advice from your local pharmacist on what product best suits your child. There was an extensive amount of coverage in national media including the Irish Independent, the Irish Examiner and the Irish Daily Mail, as well as online media on RTÉ.ie, Mumsonline.ie, DublinLive.ie and the Australian Journal of Pharmacy. Tomás Conefrey was also interviewed on Newstalk FM, Today FM, KFM Radio and Beat 102-103, and there was also a report on Dublin’s Q102. A press release was issued in advance of Electric Picnic, where pharmacists highlighted important health tips to festival goers. There was coverage in the Irish Daily Mirror and online on Joe.ie. We supported Media Planet’s 2017 Value of Vaccines campaign, which addressed the importance of immunisation from key opinion leaders. Darragh O’Loughlin wrote an article on the pharmacy flu vaccination service and Daragh Connolly was interviewed for the campaign, where he called for an expanded vaccination service through pharmacies, which featured in the Irish Independent.

R 2017

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IPUREVIEW OCTOBER 2017

IPU NEWS

Health Service Capacity Review The Department of Health is undertaking a health service capacity review to determine capacity requirements in the health service to the year 2030. This involves a detailed analysis of current and future demand for health services, capacity requirements to meet this demand and the effect of health policies on future capacity requirements. The IPU welcomes the fact that the Department of Health, in this review, is interested in assessing capacity across primary care, in recognition of the interdependent nature of capacity across the system and the ongoing developments in the way care is delivered and accessed. In our submission to the Department, we outlined how the development of pharmacy services is essential for the optimisation of healthcare services in Ireland and set out the key role that community pharmacists, working collaboratively with the other professions, can play in the development of the health service in Ireland, particularly primary care. In an environment of demographic pressures, a growing and ageing population and limited resources, the healthcare system is under unprecedented pressure, with increasing demand for healthcare resulting in hospitals being overstretched and GPs struggling with their existing workloads, which will, according to themselves, continue to increase with the ongoing expansion of universal healthcare. Pharmacists do not seek to replace GPs nor to usurp their role. On the contrary, by working collaboratively to the top of their scope, pharmacists can support GPs in providing patient care and treatment, allowing valuable GP time and resources to be applied to patients who need them most. The options available to increase health service capacity must include expanding the role of the community pharmacist and introducing properly resourced pharmacy-based services, which have been shown to operate very effectively in other countries. Our submission described a number of pharmacybased services, such as a Minor Ailment Scheme, New Medicine Service, Chronic Disease Management, Anticoagulation Service, Extended Vaccination Service and Health Check Service, that can be provided by pharmacists to the public to support and assist in the provision of primary healthcare, thus increasing the health service capacity.

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The Regional Annual General Meetings of the IPU will be taking place across the country this month and provide an ideal opportunity for us to brief you on all relevant current issues since the last AGM and, more importantly, get your views and hear your concerns. As it is an election year, representatives will be chosen at the meetings to join the local and national committees of the IPU, so, if you want to get more involved, why not put yourself forward? Don’t forget that, if your local meeting doesn’t suit, you can go to any of the other Regional AGMs. See page 12 for further details.

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IPUREVIEW OCTOBER 2017

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IPU NEWS

Save the Date Join us in the sunny South-East for Ireland’s number one pharmacy event. The 8th annual IPU National Pharmacy Conference will take place on 27 – 29 April 2018 in Clayton Whites Hotel, Wexford. We have taken on board your valued feedback to bring you a bigger and better conference for 2018 and are delighted to be working with a panel of pharmacists from around the country to develop a comprehensive and educational programme. We are planning an exciting programme, which you won’t want to miss out on. This is your conference and your opportunity to join fellow colleagues for an eventful and jam-packed weekend. At the IPU conference, we always endeavour to provide you with a huge range of events, from thought-provoking and relevant sessions to heated discussions and debates. We know that 2018 will be our biggest year yet so mark it in your calendar and we look forward to seeing you there!

DATE E H T SAVE otel hites H W n o t Clay Wexford pril 2018 27-29 A

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IPU Business Academy Our Autumn Programme for business training continues this month.

Digital Marketing & Social Media This is an interactive workshop for pharmacies who wish to increase their marketing exposure through social media. The course is suited for those who have attended the beginners training or are proficient in the use of social media channels. Date

Location

10 October

Rochestown Park Hotel, Cork

12 October

Butterfield House, Dublin

17 October

Maldron Hotel, Oranmore, Galway

19 October

Radisson Blu Hotel, Letterkenny, Donegal

Sales & Merchandising

Learn how to increase customer spend in your pharmacy by using better sales techniques and understanding how to present the retail offering through better layouts and stock merchandising. Date

Location

9 October

Butterfield House, Dublin

11 October

Rochestown Park Hotel, Cork

Finance for the Non-Financial Get a better understanding of what your Profit & Loss account and Balance Sheet say, as well as learning more about Cash Flow and KPIs for pharmacies, with this basic introduction to business finance. Date

Location

5 October

Butterfield House, Dublin To book a place on these interactive training workshops, visit the Training & Events section of www.ipu.ie.

IPUREVIEW OCTOBER 2017

IPU supports Pieta House IPU Training Programme Autumn 2017 Our autumn training programme for pharmacy staff is off to a great start and continues throughout October with CPD for Pharmacy Technicians and the Pharmacy Retail Sales course. See the table below for all of our courses, which are still available to book. You can find details and application forms on the Training & Events section on www.ipu.ie. Please send completed application forms to [email protected] or fax to 01 406 1556. Phone Janice or Susan in the Training Department on 01 406 1555 if you have any questions in relation to these courses. Course

Start Date

IPU Medicines Counter Assistant Course (MCA)

Monday 6 November, Dublin Tuesday 7 November, Waterford

Pharmacy Retail Sales Course

Monday 9 October

CPD Training for Pharmacy Technicians

Monday 9 October, Cork Monday 9 October, Galway Tuesday 10 October, Athlone Tuesday 10 October, Killarney Tuesday 10 October, Kilkenny Wednesday 11 October, Dublin Wednesday 11 October, Donegal Wednesday 11 October, Limerick Sunday 15 October, Dublin

Topic 1: Heart Health (2) Topic 2: Commonly Prescribed High Tech Drugs

IPU MCA Refresher Course

Wednesday 18 October, Dublin Wednesday 8 November, Cork

Supervisory Development Course

Tuesday 24 October

We are partnering with Pieta House, the Centre for Suicide and Self-harm Prevention and Suicide Bereavement Care, to raise awareness of the vital services Pieta House provides in centres across Ireland. Over the coming weeks, members of the IPU will receive a window sticker detailing the contact information for Pieta House, which we encourage you to display in your pharmacy to promote the charity’s services. Pieta House was established in 2006 to provide freely accessible, professional services to people who are in suicidal crisis or who are self-harming. In 2016, they expanded their service to provide suicide bereavement counselling. Pieta House has locations across Ireland and uses a solutionfocused therapy model; its approach is rooted in compassion and care. The vision of Pieta House is a world where suicide, self-harm and stigma are replaced by hope, self-care and acceptance. Commenting on this new initiative, CEO of Pieta House, Brian Higgins, said, “We are delighted to have the support of the Irish Pharmacy Union. This campaign will help us reach many more vulnerable people, potentially spreading the word of our free service to every single person who walks into a pharmacy in Ireland. “With the help of the IPU, we can continue to serve individuals and communities across Ireland, answering our phones and opening our doors for those who need our support, but may not know we’re here. Pieta House provides a completely free, professional service, but we rely on the help of our supporters and partners to reach those most at risk.” Pieta House has offered support to over 30,000 people since it first opened its doors. Over 5,800 people sought its services in the last year alone. Alarmingly, 25% of those who have come to Pieta House are under the age of 25, highlighting the importance of ensuring young people know that there is always someone available to talk to if needed.

Pharmacy Benevolent Fund clg Confined Monthly Draw The winners of the September draw were: 1st Prize (€1,000): Catherine Cleary, Craughwell 2nd Prize (€500): Rose Finlay, Tullamore Thank you to all the contributors for their continued support.

IPUREVIEW OCTOBER 2017

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IPU NEWS

Election time for IPU Committees The Regional Annual General Meetings (RAGMs) of the IPU take place this month at eight venues around the country. At the meetings, IPU members will get a full briefing on all current and upcoming issues and will have an ideal opportunity to discuss their concerns and put their views to their IPU representatives. More importantly, this year is also an election year for the national committees of the IPU. In this article, current representatives on the committees share their experiences.

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lections of regional representatives to the four national committees will take place at each of the RAGMs. These committees set the policy direction for the IPU and use their everyday experience as community pharmacists to form the basis of the IPU response to the constant challenges facing the sector. Fresh blood is always welcome to join those who have served for longer, to get the right mix of experience and new ideas, and it can be a rewarding experience for those involved.

Executive Committee The Executive Committee is responsible for governance of the IPU and oversees the implementation of the IPU’s strategy; the other committees (CPC, PCC and EPC) feed into to the Executive Committee. Joanne Hynes, Joanne Hynes totalhealth Pharmacy,

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Ballinrobe, Co Mayo, has been a member of the Executive Committee since 2011 as the Western Representative. “I have always been passionate about pharmacy and the role of the pharmacist. Day to day, I do not have enough hours in the day to cope with being a pharmacist and getting on top of the ever-growing mountain of paperwork that we are expected to cope with. I recognised that as a small independent pharmacy, I need a voice that represents me and, in Ireland, I believe that is the IPU. “The Executive Committee meets about six times per year. It’s good to get up to Dublin (I also get to Dublin from Mayo for the third Sunday in September most years but that is a whole other story). My locum and travel costs are paid. It was a little daunting at first but the Executive is a very inclusive committee and all voices are valid; there is a wonderful,

energetic, committed group of pharmacists working for the good of pharmacy. “It was enlightening to step out of my dispensary and to think about the bigger picture and to focus on all the changes that are coming down the line plus the major cuts the HSE is implementing. It has been a very challenging few years as the HSE implement more and more changes with little consultation, struggling to get pharmacists’ voices heard. As frustrating as it is, I feel the IPU is even more essential now.”

Community Pharmacy Committee (CPC) The mission of the CPC is to serve and support community pharmacists in their practices and to promote and expand their role as pharmacists by continually developing professional, ethical, business and technological ideals and standards.

John O’Connell of Haven Pharmacy O’Connells, Kilkenny, has been involved with the IPU for some years now, first as a regional rep before becoming a member of CPC, which he is currently chair of. “Pharmacy, like many professions, can be insular and you very much steer your own ship on a day-today basis. We manage our businesses independently, without much outside help or interference, and I guess I saw being part of the IPU as a way of learning more and sharing some of the ideas I reckoned I had. When I was elected to the CPC, I genuinely had little clue as to what the committee actually did and was concerned at first that I would be a fish out of water; I was wrong. I immediately felt very welcomed by the existing team and they seemed encouraged by the arrival of new faces around the table. “CPC meet at least four times annually. There are

IPUREVIEW OCTOBER 2017

COMMERCIAL FEATURE

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e do what we can to minimise the risk in our lives. As such, does it not make complete sense to protect the most valuable resource of all, life itself? After all, you are the reason you have a home, a car and other valuables. You are your own greatest asset. At some point, it is inevitable that you will leave this world; it’s simply a question of when. Imagine, for a moment, that today is your last day. Would your family be able to financially cope with your loss—and if so, for how long? Life insurance provides the best possible answer to these questions. As a financial tool, life insurance helps you defend your wealth against worst-case scenarios, and it can be used in a variety of ways.

Above all, life insurance gives you peace of mind, knowing that you have adequately prepared for the worst. Given all this, the IPU is delighted to provide an opportunity to join a new group life insurance plan underwritten by Zurich Life Assurance. This plan will be launched on 1 October 2017 and is designed for all IPU members and their employees.

n It provides a cash lump in the event of death, replacing the income you would have earned for your family had you been alive.

n Lower Premiums: By design, a group life plans’ premiums cost less than that of a personal plan.

n It shields your loved ones from the devastating effects of debt. n It ensures that your children can continue their education uninterrupted.

Why Group Life Insurance? There are several benefits to joining a group life plan. n Convenience: Rather than applying on your own, signing up for a plan through work requires a single form and no medical examination.

n Additional Protection: If you already own a life insurance plan but have not reviewed or updated it in recent years, a group life plan can supplement any gaps in your insurance needs. This is especially helpful when one is still supporting children of school age.

How Does the IPU Group Life Plan Work? The IPU group plan will cover employees and contractors aged 18 to 65 while they remain in service. Its main features include the following: n €100,000 death benefit for each covered member; n €10,000 death benefit for each of your children of up to 21 years of age; n A monthly premium of €10, regardless of age or smoker status; n Automated collection from your debit or credit card; and n Coverage ceases only upon death, upon reaching the age of 65 or ceasing of your membership with the IPU or employment with an IPU member pharmacy.

To join the plan, simply visit the Business section of www.ipu.ie and fill out the short online application form. Once approved, your coverage will begin and Zurich will send you your confirmation by PDF. Life insurance forms an integral part of wealth creation, one that no family can afford to do without. It protects what you have built over many years of hard work and relieves the financial burden on those you leave behind. And while it will never replace the loss of a loved one, it comforts the bereaved family that, even in death, you thought of their welfare first. Sign up today for the IPU Group Life Insurance Plan and protect what’s most important. The IPU Group Life Plan is arranged by Halligan Insurances. Should you have any questions relating to the plan, contact a member of their team on 01 879 7100 or [email protected].

other meetings sometimes; subcommittee meetings or meetings you may be asked to attend with the PSI, HSE or HPRA and other Government bodies. It is at these meetings that you learn so much; the meetings are enlightening and I always return to work encouraged by the experience.” “The CPC deals with the professional, ethical and business side of pharmacy. Typically we will discuss issues such as which healthcare services to promote through pharmacy, how pharmacists might utilise their skills better and more efficiently, and business and IT issues. It’s great to see some of the policies we have been involved with coming to fruition such as flu and extended vaccination services and the provision of the morning after pill for GMS patients. “We are all community pharmacists on the committee from diverse locations around the country. There are many similarities, of course, in the pharmacies we come from but you also notice how different they can be too. Some pharmacies are very involved in delivering extended services in their localities and can provide anticoagulation clinics and chronic disease management services to their patients and it is good to hear how more pharmacists are involving themselves in promoting their pharmacies as an accessible first port of call in primary care. I hope to see a roll out at some point in the near future of services that all pharmacies might provide such as a New Medicine Service and a Minor Ailment Scheme. These schemes have already been trialled in a number of pharmacies throughout the country and I believe that these initiatives and others like them are a big part of the way forward for pharmacy in Ireland. “I have learnt a huge amount from sitting on the committee, from meeting with bodies such as the PSI and HPRA, but most of all from interacting with the staff at the IPU and my pharmacist colleagues from the CPC. Being a part of the CPC has

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been a truly rewarding and engaging experience and this being an election year, I would encourage other pharmacists to get involved as new faces and new ideas are always welcome.”

Pharmacy Contractors’ Committee (PCC) The Pharmacy Contractors’ Committee looks after all matters pertaining to the public health services as they concern community pharmacy and, in particular, those community pharmacy proprietors who are contractors to the HSE. This committee has a particular responsibility for negotiating with the Department of Health and the HSE. Barry Brennan, Brennan’s Pharmacy, Tramore, Co Waterford, is the South-East representative on the PCC. “I’ve always attended as many IPU Regional AGMs and other events as possible because I find them the best way of networking with pharmacy colleagues and generally keeping abreast of developments within community pharmacy. I was aware there was a vacancy on the PCC and so approached the regional chairman to put my name forward at the RAGM. I had been asked before if I would consider getting involved but I’d never felt I had the flexibility or the time to attend meetings. “Being involved in the committee really opened my eyes to the volume of work done by the IPU on an ongoing basis supporting community pharmacy and pharmacists in Ireland. The Pharmacy Contractors’ Committee is concerned with contractual matters and so most of our work involves dealing with the Department of Health, e.g. the FEMPI submissions by the IPU, and dealing with the HSE, e.g. regarding phased dispensing. “I enjoy attending the meetings and deliberating on the various issues at hand with other like-minded colleagues. It’s also a nice variation on the day-today of being a community pharmacist.”

Employee Pharmacists’ Committee (EPC) The EPC deals with matters of relevance to the employee pharmacist members of the IPU. Members of the EPC are also co-opted onto the Executive Committee and CPC. Sinéad Ryan is the EPC representative for the Mid-West. “The IPU has a great tradition of support for employee pharmacists and I used their services regularly as a pharmacist during my supervising, support and locum roles. I have found the IPU very helpful and informative, particularly the EPC, which I have subsequently joined as a member. This committee develops initiatives that support employee pharmacists in their job; dealing with pharmacist queries, writing IPU Review topics, developing SOPs for locum pharmacists and ensuring all IPU policies support employee pharmacists and are easily searchable on the IPU website. There is a significant increase in new members in the IPU, which now boasts over 1,400 community employee pharmacists. EPC is delighted with input from many of its new members who constantly propose new ideas and ways of engaging with IPU services.

“One of my favourite aspects of the job is meeting our members and getting feedback at events like the IPU National Pharmacy Conference and helping to further serve our members and the community. The members of the EPC are all proactive. We are constantly looking to the future and to improve our function, including partaking in the working group of the IPU Academy hub and are currently developing research on recruitment and retention of pharmacists who will contribute to the profession. “I see our committee’s role as very important to ensuring the voice of community pharmacists is heard and the reputation, safety and prosperity of our profession are upheld. EPC has active representation on other IPU committees, including the Executive Committee, ensuring that the professional and economic interests of employee pharmacists are represented and implemented into IPU policies.” If you are interested in putting your name forward for election and would like some further information, please contact the secretary of the relevant committee.

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CM

MY

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CMY

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Committee

Secretary

Executive

Jim Curran / [email protected]

CPC

Pamela Logan / [email protected]

PCC

Derek Reilly / [email protected]

EPC

Susan McManus / [email protected]

Date

Region

Venue

16 October

South-East

Newpark Hotel, Castlecomer Rd, Kilkenny

17 October

Dublin

Clarion Hotel, Liffey Valley, Dublin 22

18 October

North-West

Great Northern Hotel, Bundoran, Co Donegal

19 October

North-East

Ardboyne Hotel, Navan, Co Meath

23 October

West

McWilliam Park Hotel, Claremorris, Co Mayo

24 October

Midlands

The Tullamore Court Hotel, Tullamore, Co Offaly

25 October

Mid-West

The Strand Hotel, Ennis Rd, Limerick City

26 October

South-West

The Oriel House Hotel, Ballincollig, Co Cork

IPUREVIEW OCTOBER 2017

BUSINESS Jim Curran, Director of Communications and Strategy, IPU

IPU Pre-Budget Submission The IPU’s PreBudget Submission 2018 was presented to Government in August. In this article, Jim Curran, Director of Communications and Strategy, IPU, provides a summary of the key issues addressed.

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Unwinding of FEMPI The Financial Emergency Measures in the Public Interest (FEMPI) Act 2009 and the regulations made under it were used to cut payment rates to pharmacists and other professionals, which, if it were not for the emergency in the State’s finances, would have been unlawful. Since 2009, there has been a minimum of €1.23 billion in cuts to payments to pharmacies under FEMPI. This comprises €456 million in cuts to dispensing fees and mark-ups (see table 1.1 below) and €776 million (table 1.2) in cuts to the wholesale margin/ingredient cost. By

any measure, the cuts in the amounts and rates paid to community pharmacy contractors under the 2009, 2011 and 2013 regulations have been exceptionally severe in their effect on community pharmacy contractors but have had a significant impact in achieving savings for the State. Since 2009, €2.64 billion has been extracted from the community pharmacy sector, €1.41 billion of which was not under FEMPI. For example, the savings achieved under Reference Pricing alone amounted to an extraordinary €313 million by the end of July 2016.

IPUREVIEW OCTOBER 2017

Table 1.1: Reductions in Fees and Mark-ups Paid to Pharmacists by the State Year

Pharmacy fees & mark-ups

No. of items dispensed under State schemes

Mark-up & fees per item

Reduction per item since 2009

State savings

–

73,500,000

€5.05

€0.91

€66,885,000

2015

€389,740,000

73,542,223

€5.30

€0.91

€66,923,423

2014

€381,070,000

72,715,536

€5.24

€0.97

€70,534,069

2013

€393,930,000

74,378,504

€5.30

€0.91

€67,684,438

2012

€403,860,000

75,724,736

€5.33

€0.88

€66,637,767

2011

€386,630,000

72,023,261

€5.37

€0.84

€60,499,539

2010

€372,990,000

69,251,377

€5.39

€0.82

€56,786,129

2009

€420,960,000

67,825,991

€6.21

–

–

–

–

–

–

€455,934,014

2016 (estimate)

TOTAL

Table 1.2: Reductions in Medicine Reimbursements Paid to Pharmacists by the State PCRS payments for medicines

No. of items dispensed under State schemes

Cost per item

Reduction per item since 2009

FEMPI reductions

State savings

–

73,500,000

€13.01

€5.77

€85,500,000

€424,095,000

2015

€956,750,000

73,542,223

€13.01

€5.77

€85,461,329

€424,338,627

2014

€979,010,000

72,715,536

€13.46

€5.32

€87,449,695

€386,846,652

2013

€1,053,290,000

74,378,504

€14.16

€4.62

€94,084,728

€343,628,688

2012

€1,161,460,000

75,724,736

€15.34

€3.44

€103,746,972

€260,493,092

2011

€1,114,610,000

72,023,261

€15.48

€3.30

€99,562,113

€237,676,761

2010

€1,191,880,000

69,251,377

€17.21

€1.57

€106,464,227

€108,724,662

2009

€1,273,770,000

67,825,991

€18.78

–

€113,779,020

–

–

–

–

–

€776,048,083

€2,185,803,482

Year

2016 (estimate)

TOTAL

Having come through a very difficult period, the economy is now recovering strongly, which is having a very positive impact on all fiscal indicators and the international reputation of Ireland. In line with the growth in the economy, there has been an unwinding of FEMPI for public servants. The cost of the restoration of public pay under the FEMPI Act 2015 will be €844 million up to September 2018, which is equivalent to 38% of the €2.2 billion savings made in the public pay bill under FEMPI. The IPU is calling for the immediate unwinding of FEMPI measures which

IPUREVIEW OCTOBER 2017

were applied to community pharmacy contractors, in recognition of the significant contribution they have made and continue to make towards achieving savings for the State during the recent financial crisis and their ongoing cooperation with reimbursement reform and the delivery of key audit and accountability measures.

Employment costs The reduction of the 8.5% employers’ PRSI rate to 4.25% for those earning less than €356 per week was announced as part of the

2011 jobs initiative and was in place until the end of 2013. This welcome support for job creation and sustainability was not renewed after that date. Consequently, the ending of this measure had a significant impact on many retail pharmacies, particularly those employing part-time staff. There is anecdotal evidence of pharmacies having to reduce staff hours and, in some cases, let staff go as a result of the measure not being extended. The current level of PRSI/ Universal Social Charge on top of existing income tax rates is rendering prohibitive the costs associated with employing

additional staff members and is also jeopardising the ongoing viability of the employment of existing levels of staff in many pharmacies. Together with addressing the level of taxes imposed on employees to make employment more attractive at the margins, it is also essential that employers’ PRSI rates are addressed in order to incentivise pharmacy and other retail owners to sustain and increase employment. A first step would be to reinstate the 4.25% PRSI rate for lower paid workers from the current 8.5% rate, up to the threshold of €376.

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The measure should be reintroduced for a three-year period to assist in sustaining and increasing employment in the sector. Employers’ PRSI is a direct tax on labour and should be reduced as a matter of urgency to offset the substantial labour costs involved in hiring staff.

PAYE allowance for Self-Employed The disparity in the tax treatment between the selfemployed and PAYE workers needs to be addressed, in particular the discrimination against directors and the self-employed with regard to not being able to avail of the full PAYE tax allowance. The earned income tax credit, which increased to €950 in Budget 2017, needs to be increased to the same level as the employee credit (currently €1,650) immediately and subsequently increased in line with the PAYE tax credit to ensure equalisation is maintained into the future.

Regulatory costs The fees charged to pharmacies for registration with the Pharmaceutical Society of Ireland (PSI) are excessive and are a multiple of costs in similar jurisdictions. The annual registration fee each pharmacy must pay to the PSI is €2,135 (€3,325 on first registration). In

Northern Ireland, the firsttime registration fee for a pharmacy premises is £113 and then £317 per annum for each year after registration, which is only a fraction of the cost of registration in the Republic of Ireland. It is unsustainable for one arm of the State, the HSE, to continually drive down unit payments to the pharmacy profession (as has happened under the FEMPI Act and the Health [Pricing and Supply of Medical Goods] Act) while, at the same time, another arm of the State, the PSI, continues to enjoy the highest pharmacy registration fees in Europe, if not the world. In order to ensure the sustainability of local pharmacy services, these charges need to be immediately brought into line with those in other European countries, in particular those which apply across the border.

Nationwide DUMP (Disposal of Unused Medicines Safely) Scheme Waste charges are an issue for all small businesses. For pharmacies, the costs are higher than for other retailtype businesses due to the specialised collection and disposal services required for the disposal of medicines. There are significant public safety benefits, however, to encouraging people to dispose of their unused or

out-of-date medicines at their local pharmacies but this must be done without adding significant costs to the pharmacies receiving the medicines. Most community pharmacists accept unwanted medicines returned by patients to their pharmacies and dispose of them at their own expense. However, this is no longer sustainable as it is becoming an increasingly expensive burden at a time when pharmacies are under unprecedented economic pressure. To assist in alleviating these costs, a nationwide DUMP Scheme should be introduced by the HSE and all local authorities that would encourage the public to return their unused medicines to pharmacies, which would have significant health and public safety benefits and, at the same time, alleviate the significant cost for pharmacies providing this service.

Introduce further measures to rejuvenate city, town and village centres

villages through their local authorities to address the challenges of creating a vibrant and viable town centre, which will support enterprise and economic development across towns and villages throughout Ireland. To address the challenges of town centre renewal of all sizes of villages, towns and cities, the IPU would like to see the recommendations in the framework document being rolled out across local authorities and central Government with the support of other key stakeholders including pharmacy and other retail representatives. Recommendations include greater coordination across local authorities in their approach to town centre management; identifying further funding streams for town centre renewal; a National Town Centre Health Check Programme; and a central portal for town centre renewal resource material and case studies.

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A Retail and Town Centre Renewal working group, set up by the Retail Consultation Forum, prepared a Framework for Town Centre Renewal 1, which was launched by Minister Mitchell O’Connor in April 2017. The framework will support towns and

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“ In England, Scotland and Canada, for example, where demand for GP services exceeds the available capacity, the unique skills and expertise of pharmacists are being used to enhance access to healthcare.”

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IPUREVIEW OCTOBER 2017

Prescription levy The medical card prescription levy, currently €2.50 per item, has increased fivefold since it was first introduced in June 2010 at €0.50 per item. Many patients, particularly those on fixed incomes, cannot afford to pay the levy. Instead, they gamble with their health every day either by reducing their medication or by stopping it entirely. The ultimate outcome is sicker patients with more complex medical needs needing advanced care in an already extremely overburdened health system. The imposition of the levy is creating more future demand for a health service that is already struggling to cope. While the levy was reduced in the last budget for those aged 70 and over and their dependants (down to €2.00 with a monthly cap of €20), the IPU would like to see a complete phasing-out of the levy and, at the very least, that it is not applied to especially vulnerable patients including those in residential care settings, homeless patients, patients receiving treatment under the Methadone Treatment Scheme in respect of other medication that they may require, patients with intellectual disabilities, and palliative care patients.

Expanded role for pharmacists In an environment of demographic pressures, a growing and ageing population and limited resources, the healthcare system is under

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unprecedented pressure, with increasing demand for healthcare services resulting in hospitals being overstretched and GPs struggling with their existing workloads, which will, according to themselves, continue to increase with the ongoing expansion of universal healthcare. There is clear evidence to show that pharmacy-based services introduced in other jurisdictions have led to considerable improvements in patients’ health outcomes and considerable savings to healthcare budgets. In England, Scotland and Canada, for example, where demand for GP services exceeds the available capacity, the unique skills and expertise of pharmacists are being used to enhance access to healthcare. In Canada, the government mind-set has changed; all professions are now expected to practise to the full extent of their skills to maximise the public benefit of healthcare training and resources. Thus, pharmacists’ scope of practice has been extended to include Chronic Disease Management: monitoring patients with chronic illnesses, renewing and adjusting their prescription medicines to ensure tighter control of their symptoms. Despite a severe shortage of primary care doctors, extending pharmacist responsibilities in this way has resulted in better access to healthcare and improved management of illnesses such as heart disease and diabetes. Canadian pharmacists are

also authorised to prescribe medications in emergency situations, when it isn’t possible to get a doctor’s prescription. Data from Scotland shows that in-depth Medicine Use Reviews, conducted by pharmacists with patients suffering from chronic illnesses, reduced hospital readmission rates by a third. Introducing additional pharmacy-based services would command strong public support. In March this year, a nationwide survey2 conducted by Behaviour & Attitudes found very strong support for expanding the role of the pharmacist as a healthcare provider; 96% said they “would be in favour of the pharmacist being able to prescribe some medicines for minor ailments”, while 93% said they would like to see the pharmacy “offering services such as blood pressure or cholesterol testing at the pharmacy for a reasonable cost”. The role of the pharmacist in Ireland should be expanded to include the introduction of pharmacy-based services available in other jurisdictions including a Minor Ailment Scheme, New Medicine Service and an expanded vaccination service, which have been shown to offer cost-effective access to improved healthcare.

Conclusion It is imperative that the Government reviews and addresses the State-imposed and State-controlled costs on small businesses, including pharmacies, in order to

maximise sustainable employment and to ensure the continuing provision of high-quality pharmacy services in local communities. It is also essential that no further costs are imposed on pharmacies, which could have a detrimental impact on the survival of the pharmacy or threaten existing employment levels. There must be immediate action to commence the unwinding of FEMPI measures as they applied to community pharmacy contractors, in recognition of the contribution they have made to achieving significant savings for the State during the recent financial crisis. Lastly, the IPU believes that developing the role of the pharmacist will deliver better patient outcomes, as well as generating efficiencies and savings. The challenge now is to ensure that community pharmacy is enabled to deliver more into the future and this requires a new and more strategic approach to be agreed for the delivery of community-based healthcare in the context of overall healthcare reform. This year’s budget can go some way to achieving this. A copy of the full submission is available at www.ipu.ie. References 1. Retail and Town Centre Renewal Working Group (2017) A Framework for Town Centre Renewal. Available at: www.djei.ie/en/Publications/AFramework-for-Town-CentreRenewal.html 2. Behaviour & Attitudes (2017) Pharmacy Usage and Attitudes.

IPUREVIEW OCTOBER 2017

PROFESSIONAL Deirdre Ryan, Screening Promotion Manager, National Screening Service

Update from the National Screening Service BreastCheck Almost 50,000 women did not attend their BreastCheck appointment in one single year, meaning a lot less women will have cancer detected early enough to receive appropriate treatment. The HSE National Breast Screening Programme offers free mammogram appointments to eligible women every two years, an appointment that could save a life and one that should be kept. This is the message from the National Screening Service who is encouraging all women to participate when invited. The appeal comes as part of Breast Cancer Awareness Month, which runs through October. The programme recently published its screening statistics for 2015 – 2016, highlighting some key achievements, making it a significant year for the programme. The report highlighted that BreastCheck invited 198,986 women for

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screening with a total of 145,822 women attending for a mammogram and 986 cancers detected. This is both the highest number of women ever screened and the highest number of cancers diagnosed in a single year by BreastCheck since the programme commenced in 2000. However, due to the growth in population numbers in the BreastCheck age cohort (currently 50 to 66), the overall uptake rate stands at 74.7%, which shows a decrease on the previous year (76.5%). Although the uptake rate remains above the minimum acceptable level of 70%, there are still many women who are not attending when invited. The programme is committed to maintaining a strong uptake rate but aims to improve this even further. Almost 90% of women who come for their first BreastCheck mammogram come back again the next time they are invited.

However, there is a problem with women not taking up the first invitation and the numbers not attending as first-timers is increasing. BreastCheck would appreciate any support a pharmacy may wish to give to encourage these younger women to consider attending. BreastCheck would welcome contact from such women and would be happy to register them for the programme. Further details are available on www.breastcheck. ie or Freephone 1800 45 45 55. BreastCheck is currently extending the age range within which women can be screened. Currently the ages are 50 to 66 with the latter figures moving incrementally to 69 between now and the end of 2021. Any pharmacist who would like to have some BreastCheck promotional material for display can order these free-of-charge on www.healthbrochures.ie.

BowelScreen – the National Bowel Screening Programme The aim of BowelScreen is to reduce mortality from bowel cancer in men and women in Ireland. It is a quality-assured bowel cancer screening programme, based on international evidence that will, over time, offer free bowel screening to over one million people aged 55 to 74. Currently, men and women in the 60 to 69 age group are being offered this free test. The test, also known as a FIT kit, is easy to use, is non-invasive and can be carried out in the privacy of one’s own home. In Ireland, bowel cancer is the second most common newly diagnosed cancer among men and women and the second most common cause of cancer death. Each year, over 2,000 new cases are reported. The number of new cases is expected to increase significantly over the next 10 years, due mainly to an increasing and ageing population.

IPUREVIEW OCTOBER 2017

The primary objective of bowel screening is to detect pre-cancerous adenomas in the lining of the bowel, thereby making screening a preventative health measure. In fact, a national bowel screening programme has the potential to be one of the most effective public health interventions in the Irish healthcare system. In the first round of screening (2012 – 2015), approximately 13,000 such growths were removed. In addition, another 521 participants were diagnosed with bowel cancer. Over 71% of the cancers detected were stage I or II, meaning that they were detected at an early stage, when they could be more easily treated. Despite the good news of early detection through BowelScreen, the uptake rate is still somewhat low with an overall rate for the first round of 40%. There is a significant gender gap in uptake with only 36% of men as compared to 44% of women engaging

with the programme. This is particularly worrying as men are statistically more likely over their lifetime to develop bowel cancer. While the National Screening Service is confident that these figures will improve during the course of the second round (2016 – 2017), it would very much welcome the assistance of pharmacists in promoting the programme to their local communities. As with BreastCheck, free promotional materials can be accessed via www. healthbrochures.ie. In addition, if any pharmacist would like to receive a demonstration FIT kit (the home test for BowelScreen), please email deirdre.ryan1@ screeningservice.ie. Men and women between 60 and 69 years of age can check that they are registered for free bowel screening online at www.bowelscreen.ie or by calling Freephone 1800 45 45 55.

BowelScreen FIT kit (BowelScreen home test): The home test kit is free, fast and non-invasive

“ The primary objective of bowel screening is to detect pre-cancerous adenomas in the lining of the bowel, thereby making screening a preventative health measure.” IPUREVIEW OCTOBER 2017

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PROFESSIONAL Rachel Dungan MPSI, ACC, PMC

S.T.E.P.S. to Effectively Communicating New Reimbursement Restrictions to Patients In this article, Rachel Dungan MPSI explores some principles to best communicate new reimbursement restrictions to patients, to create optimal outcomes for all involved. Pharmacist perspective When you receive a HSE circular outlining the latest reimbursement restrictions, what do you say to yourself? Does it sound something like this? “What next? Yet another HSE circular relating to dispensing reimbursement restrictions. More administration. More hassle. Another process to remember. Another exception to communicate to staff and locums. These restrictions are not my fault. Why are pharmacists always the ones to carry the can, take the

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financial hit and shoulder abuse from the patients affected? It’s not fair. It isn’t what I became a pharmacist to do. I feel imposed upon, frustrated and disillusioned. How am I supposed to explain the situation to Mrs A without getting eaten alive? All I’m going to get is grief, yet I’m only the messenger. I hate conflict and I feel like the piggy in the middle.” This train of thought is completely understandable and easy to justify. And yet, does it serve you? Does it serve your patient?

Customer perspective Now imagine you are Mrs A. You have waited at the doctor’s surgery for an hour with your mother who has nerve pain associated with shingles. You are worried and exhausted. You run into the pharmacy to collect her prescription for lidocaine 5% plasters. You meet the pharmacist who tells you he can’t dispense the plasters because of a new HSE restriction. You see red.

IPUREVIEW OCTOBER 2017

“What next? More hassle. HSE restrictions are not my fault. Why are patients like me and my Mum always the ones to carry the can? We’ve paid taxes all our lives and at this stage we need to be taken care of, not treated like drug-abusing criminals. It’s not fair. It isn’t as if I don’t have enough on my plate already. I feel imposed upon, frustrated and scared. All I’m getting is grief, yet I’m only my mother’s messenger. I hate conflict and I feel like the piggy in the middle.” So here are two people, pharmacist and customer, neither of whom created the challenge they both face, people who should be working together to navigate the challenges, but instead have pitted themselves against each other, resulting in both feeling frustrated, isolated and misunderstood. Worse still, unless one of our protagonists changes tack, this conversation risks ending in an altercation in which both pharmacist and customer feel mistreated, frustrated and resentful, and the situation remains unresolved. Loselose situations like this, out of desperation to be heard, sometimes result in complaints to the PSI. Indeed, in the PSI’s Annual Report of the Preliminary Proceedings Committee (PPC) 2013, it was noted that many situations that gave rise to complaints involved the manner in which information was communicated to a patient.

n What impact do I want to have on this other person? n If this customer was a loved one, such as my parent, my grandparent or my child, how would I want them to be treated? n What perceptions, stereotypes or assumptions am I making? Am I open to these being challenged?

In what manner does our customer want the pharmacist to communicate? “The HSE reimbursement system is a mystery to me. I’m so worried about Mum. I really want to feel as if SOMEONE has my back and will help me to help my mother but right now it feels as if it’s me against the world. It would make all the difference if I truly believed the pharmacist was genuinely interested in working with me to make sure Mum gets pain relief and not feel as if they are just protecting their bottom line. I wish that someone in the healthcare system would actually LISTEN to me and act in a genuinely patientcentred manner. I am more than willing to work with the pharmacist so that together we can sort this out.”

How could the pharmacist communicate differently to align with the customer rather than unintentionally create an adversarial experience? Before the consultation You must balance your professional and administrative responsibilities with compassionate attention to your patient’s needs. Being more mindful of your own and others’ stress and tension points requires you to consciously and consistently create the space to raise your own personal leadership and self-care skills. Pre-consultation intention – self-audit n How do I want the customer to FEEL at the end of this consultation?

n What language will I use to convey that I am on the patient’s side and my intention is to collaborate with them to resolve the situation? During the consultation The S.T.E.P.S Model provides a simple and effective framework to help you to guide difficult reimbursement conversations towards a winwin outcome. That means that both the pharmacist and the customer feel good as a result. n S – ‘Seek to understand’: You have a profound ripple effect on your patients and customers, whether or not you are consciously aware of it. Patients have a strong desire to be understood, to gain feedback and support and to know that you, their pharmacist, genuinely has their best interests at heart. As a pharmacist, it’s difficult to really know what your patients are thinking

” Being more mindful of your own and others’ stress and tension points requires you to consciously and consistently create the space to raise your own personal leadership and self-care skills.”

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IPUREVIEW OCTOBER 2017

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+ Acts within 5–10 minutes + Long-lasting ease of breathing + Contains no preservatives Septanazal:The nasal spray solution contains xylometazoline hydrochloride and dexpanthenol. Indicated for adults and children over the age of 6 for reducing swelling of the nasal mucosa in rhinitis and as supportive treatment for healing the mucous membrane lesions, for the relief in vasomotor rhinitis and for the treatment of nasal respiratory obstruction after nasal surgery. Adults and children over 6 years of age: The usual dose of Septanazal for adults and children aged 6 years or over is one spray into each nostril up to 3 times a day. Regarding the duration of treatment in children, a doctor should always be consulted. Precautions: This medicinal product may be used only after a careful assessment of the risks and benefits in cases of: patients being treated with the monoamine oxidase inhibitors (MAOIS) and other drugs which potentially increase blood pressure, increased intraocular pressure, especially narrow-angle glaucoma, serious heart and circulatory diseases (e.g., coronary heart disease, hypertension), phaeochromocytoma, metabolic disorders (e.g., hyperthyroidism), porphyria and prostate hyperplasia. In chronic rhinitis it may be used only under medical supervision owing to the danger of the atrophy of the nasal mucosa. The prolonged use and overdose of decongestant sympathomimetics in particular may lead to reactive hyperaemia of the nasal mucosa. This rebound effect causes narrowing of the airways and, consequently, the patient uses the medicinal product repeatedly until its use becomes permanent. The consequences are chronic swelling (rhinitis medicamentosa) or even atrophy of the nasal mucosa. In less severe cases consideration can be given to discontinuing the use of the sympathomimetic in one nostril initially and, after the symptoms have abated, changing to the other side in order to maintain at least part of the nasal respiration. Direct contact of the medicinal product with the eyes should be avoided. In case of misuse or use of excessive amounts of the spray, the absorption of xylometazoline can cause systemic adverse effects, particularly in children (cardiovascular and neurological adverse effects) (see sections 4.8 and 4.9). Concomitant use of the product with medicinal products for local or systemic treatment of the flu and sympathomimetics contained in cough-and-cold medicines (e.g.: pseudoephedrine, ephedrine, phenylephrine, oxymetazoline, xylometazoline, tramazoline, naphazoline, tuaminoheptane) is not recommended in order to avoid an increased risk of possible cardiovascular and neurological adverse effects (see section 4.5). Contraindications: Hypersensitivity to the active substances or to any of the excipients listed in section 6.1 of the SPC, dry inflammation of the nasal mucosa, history of transsphenoidal hypophysectomy or other surgical interventions which expose dura mater. Septanazal for adults is contraindicated in children under 6 years of age. Fertility, pregnancy and lactation: Septanazal should not be used during pregnancy, as there is not sufficient data available concerning the use of xylometazoline hydrochloride by pregnant women. Septanazal should not be used during the lactation period, since it is not known whether xylometazoline hydrochloride is excreted in the breast milk. There is no data on the influence of Septanazal on fertility. Adverse reactions: Uncommon: hypersensitivity. Rare: palpitations, tachycardia, hypertension. Very rare: restlessness, insomnia, fatigue, headache, hallucinations, rebound congestion, nosebleed, convulsions. Not known: burning and dryness of nasal mucosa, sneezing. Shelf life: 2 years. Legal category: Medicinal product not subject to medical prescription. Marketing authorisation number: PA1347/058/002. Marketing authorisation holder: Krka, d. d., Novo mesto, Šmarješka cesta 6, 8501 Novo mesto, Slovenia. http://www.hpra.ie/img/uploaded/swedocuments/LicenseSPC_PA1347-058-002_19012017142039.pdf Date of Preparation: June 2017. Additional information is available on request from Krka Pharma Dublin Ltd. Unit 4A, Leopardstown Business Centre, Ballyogan Road, Leopardstown, Dublin 18. D18 KX88. Reference number: 01-09-2017.

about, what’s troubling them or what their expectations are – unless you create dedicated time to really listen to them. Truly listening requires us to actively engage with what matters most to your patients. When they share their opinions (even ones that appear to us as criticism), ask questions and encourage them to elaborate and expand upon their perspectives. Over time, this creates a safe space for the nub of the issue to emerge and be dealt with. Once you clearly understand the customer’s ideas, concerns, expectations and desired outcome, summarise them back to the customer so they know you have listened attentively and they feel heard.

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n T – ‘Then be understood’: Clearly and concisely explain the new reimbursement situation, why it has been introduced and what this means for them. Use written resources, such as the IPU Professional Resources and the Medicine Management Programme’s Information for Patients, to support your explanation. Check that the message you intended to send was the message the customer received and invite further questions. n E – ‘Empathise with others’: When you take the time to put yourself in your customer’s shoes and fully understand (not necessarily agree with) their perspective,

communication becomes less defensive and more open to collaboration. Acknowledge the challenges they face and reassure them that you will be their advocate and ally as you work together to resolve them. n P – ‘Problem solve’: Once you have reached agreement on the desired outcome (e.g. Mum is pain-free), you can brainstorm potential solutions to resolve it in a mutually satisfactory way, with you acting as the patient’s advocate with the customer as your ally. n S – ‘Safety net’: Patient safety is your first priority. This stage analyses the proposed solution to identify any potential pit-falls and agree protocols to follow up.

Post consultation Reflect on, record and evaluate your learning after the consultation. n What did you do well? n What did you learn about yourself? n What did you learn about the impact of your approach in that situation with that customer? n What could you do differently next time?

Rachel Dungan is founder of 4Front.ie, creator and facilitator of 4Front’s L.E.A.D and OTC Pharmacy Excellence Programmes, which combined with team behavioural style profiling, transform the impact of pharmacist-led teams through Leadership, Engagement, Alignment, Discipline and Skills to optimise patient-centred care.

IPUREVIEW OCTOBER 2017

Some pitfalls to avoid (and alternative strategies to employ) n Playing the blame game: Do not shirk your responsibility to align with the patient and help them to deal with the situation. The blame game creates a victim mentality where everyone feels hard done by. Take personal responsibility; it feels better and is more empowering. n Being appeasing or overly apologetic: You are part of the solution, not the problem. Be sure your customer and their doctor know that. n Arguing: You are a member of the patient’s team, not the opposition. Clarifying and resolving problems and creating healthy relationships is where focus is best placed. n Interrupting: People feel disrespected when their train of thought is interrupted; listen without interrupting. n Distractions: Have the conversation in the privacy of the consultation room. n Jargon or ambiguous explanations: Be clear, concise and get to the point. n Them vs Us mentality: Remember, you are on the same side. Collaboration (not competition) will result in win-win outcomes.

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PROFESSIONAL Alan Reilly, Head of Information and Technology, IPU

Healthmail – Using Secure Clinical Email In collaboration with the HSE, the IPU launched the Healthmail service for community pharmacy in March 2017, enabling pharmacists to access and share patient clinical information in a fully secure manner. Six months on, Alan Reilly, Head of Information and Technology, IPU, reports on its usage and explores its potential.

H

ealthmail is a secure clinical email system provided by the Office of Chief Information Officer (OoCIO) in the HSE. The initial implementation of Healthmail, which went live in November 2014, was for GPs and their support staff, allowing communication of patient-identifiable clinical information with clinicians in

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primary and secondary care. As a service, Healthmail is being extended to all primary healthcare providers. In preparation for the Health Information and Patient Safety Bill, the IPU worked with eHealth Ireland (part of the HSE) to implement Healthmail in community pharmacy. Presently, a group of connected agencies have access to Healthmail, including GPs, pharmacies and HSE staff.

IPUREVIEW OCTOBER 2017

Patient safety In the interest of patient safety, pharmacies regularly need to communicate patient information and treatment with GPs, Primary Care Teams, Community Intervention Teams, consultants and pharmacists in secondary care. They can now use Healthmail for this, ensuring the right information is going to the right recipient in a secure and timely process. The anticipation is that Healthmail, by replacing faxes and some phone calls, will bring primary care communications into the 21st century, promoting healthcare that is up to date, effective and consistent.

Hospital to Pharmacy Before being made available to community pharmacy, Healthmail was trialled as part of a pilot at Naas General Hospital and St. Luke’s Kilkenny to evaluate a new model of collaborative discharge medication reconciliation and computergenerated discharge prescriptions; Healthmail was used to communicate patient information between the hospitals and pharmacies in the surrounding areas. The pharmacy department at St. Luke’s continues to use Healthmail, saying, “As pharmacists involved with Healthmail from the initial pharmacist trial in 2016, we have found Healthmail to be a very welcome addition to our communication strategies. We also believe it has helped improve communication across the interface with both community pharmacists and general practitioners. In the main, we use it to transfer discharge prescription information to GPs and community pharmacies, but it has also allowed us to receive queries from community pharmacies and GPs on various issues such as discharge prescription queries and NOAC queries, or occasionally just to say “thank you” for the information.” Sinead McCool MPSI says,

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“I think it is important to remind people that the Healthmail service allows community pharmacists communicate with personnel in all HSE hospitals and services as well as each other and their local GPs.”

Communicating with GPs GP engagement is crucial; making arrangements with your local healthcare providers about how Healthmail can be used is key to the success of the service. Sheila O’Loughlin MPSI anticipates the potential benefits of adopting Healthmail, explaining a familiar scenario faced by pharmacists, “On a day-to-day basis, I send faxes and make phone calls to GP surgery receptions to communicate and liaise with the relevant healthcare professional. I understand that phone calls to healthcare professionals may still be necessary in certain circumstances but a reliable system like Healthmail will enable me to easily communicate messages that are important but not urgent.”

Communicating with the PCRS Healthmail is a communication tool; the number of use cases will increase as the tool is adopted. In community pharmacy, Healthmail should be used to communicate patient identifiable information with the HSE. The PCRS recommends that pharmacies use Healthmail for any High Tech-related matters as there is sensitive data associated with these orders and queries.

Healthmail in practice

Vaccination notifications

Jack Shanahan MPSI, of the IPU IT Steering Group, was one of the first to sign-up, “As soon as Healthmail became available, I signed up for it. The first thing I did was send an email to all the local GPs telling them that I was live on the system. I got more replies than I expected. Following up with the non-responding GPs, it was clear that email of any type was not part of their normal practice. I have found Healthmail very reliable; the only interruption to service was the time of the WannaCry ransomware, where most of the network access was suspended for a few days. I now use Healthmail regularly for non-urgent medical queries about specific patients. It is fairly informal and I find that it works well. I suspect that it comes down to how good your relationship is with the GPs. We also have had some Healthmail contact with the ostomy specialist nurse in the local hospital. My big wish is that the private hospitals will get access. It would be a godsend if we could contact private consultants. Like most pharmacists, I am frustrated by the number of unanswered calls we make to consultants. In these cases, Healthmail could act as an incentive to reply, as you can see if the email has been received. I see a day where Healthmail will be an integral part of the dispensary suite.”

During vaccination season, Healthmail is a simple and effective tool to communicate a notification to a patient’s GP, saving on paper and faxes. Jack concludes, “Healthmail is both beneficial for pharmacists and patients. It provides pharmacists with an electronically secure mechanism for communicating with other healthcare professionals. Whether it is a list of current medications or a vaccination notification, the ability to send confidential patient information without using fax and producing reams of paper is positive progress. It is a visible development in the sphere of secure communication of health information, and pharmacy is right there in the mix with this progressive initiative.” Finally, in praise of Healthmail and the team behind it, Sinead said, “Anecdotally, many pharmacists have said it is a bit like internet banking: initially you maybe could not see all the benefits but now you couldn’t imagine life without it. The Healthmail team has also been very helpful, providing us with updated lists of those with Healthmail accounts.”

More information To learn more about Healthmail and its potential use cases, visit www.ipu.ie/ healthmail. To register, go to www.healthmail.ie.

Data protection In general, Healthmail offers data security for sensitive health information and using the system is good practice with respect to obligations of community pharmacies in relation to data protection regulations.

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PROFESSIONAL Michele O’Brien, CEO, Irish Osteoporosis Society

Osteoporosis: What you need to know Osteoporosis affects men, women and children. 25% of men and 25% of women over 50 will break a bone from osteoporosis. 20,000 people are undiagnosed, which is only 15% of those with bone loss. The reason for this is due to a lot of misinformation regarding the disease; lack of correct information and education is a major factor.

T

he cost of fractures in Ireland was €500 million in 2013 and is estimated to be €1 billion by 2025. There are 3,000+ hip fractures a year in Ireland at a cost of €55,000 each. 20% of hip fracture patients aged 60+ will pass away within six to 12 months. They die from the secondary effects of a fracture, e.g. a blood clot, pneumonia or infection. 50% of hip fracture patients aged 60+ will lose their independence (unable to wash, dress or walk across a room unaided); many of these people are blocking much-needed hospital beds throughout the country.

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IPUREVIEW OCTOBER 2017

Skeleton progression

Red Flags that a person may have undiagnosed bone loss 1. Anyone who breaks a bone from a trip or fall, even on cement. 2. A person losing height. 3. A person’s shoulders becoming rounded. 4. A Dowagers hump developing. 5. Back pain: lower, mid and upper pain. Those with intermittent back pain may have undiagnosed vertebral fractures.

Is osteoporosis treatable? Yes, we have 90+ year olds who have reduced their risk of fractures; it is actually reversible in certain cases. The Irish Osteoporosis Society (IOS) website has a number of case stories showing that patients can significantly improve. (See www.irishosteoporosis.ie > Osteoporosis > Patient Stories.)

How can a person be tested for osteoporosis? The only test recommended by the Irish Osteoporosis Society (the national experts on osteoporosis) is a DXA scan of a person’s spine and hips. A DXA scan with an LVA (lateral vertebral assessment) is recommended if a person: n Has lost height; n Their head is forward from their body; n Has developed a dowagers hump; or n Has back pain, especially mid or upper back pain. The IOS does NOT recommend ultrasound of the heel, tibia or forearm for the screening or diagnosing of bone loss.

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What treatments are available for bone loss? There are different types of treatments available and what treatment a person follows should be based on the below: 1. If the person has a fracture; 2. The results from a DXA scan of the person’s spine and hips; 3. The causes of the person’s bone loss; 4. The person’s medical history; and 5. The person’s lifestyle.

What can a person do to reduce their risk of fractures? Considering that osteoporosis is the leading bone disease in the world, it is essential that everyone checks to see if they have risk factors for bone loss. The IOS has an extensive questionnaire that assists finding risk factors for bone loss. Pharmacists can help to significantly decrease the amount of people losing their independence by educating their patients on this topic and/or referring to the IOS for extensive information.

Prevention of bone loss To prevent bone loss, people should consume the recommended daily amounts of calcium and vitamin D, preferably through food. Supplements are available for those who cannot get them through food. It is very important that people do not take more than the recommended amounts as this can cause other issues. There is a worldwide epidemic of low levels of vitamin D, which not only cause bone loss but place a person at risk of several types of cancer, MS and mimics the symptoms of fibromyalgia. Those with eating disorders are high risk for bone loss.

Exercise and bone loss Weight-bearing exercise helps to reduce a person’s risk of losing bone. However, it is essential that people check to see if they have risk factors for bone loss prior to starting any form of exercise, other than walking. Those with bone loss should contact the Irish Osteoporosis Society for advice in this area, as research shows that the majority of fractures occur in the moderate to marked osteopenia range.

Those with bone loss should be assessed by a chartered physiotherapist (PT) who deals specifically in bone loss, prior to beginning any form of exercise. The PT should be able to thoroughly explain the person’s DXA scan report to the person, in order to put them on a safe and appropriate programme. Just because a person looks fine, it may not be so as it is the inside of their bones that are affected. This is why those who do exercise and eat a healthy diet need to check if they have risk factors. Some women lose up to 30% of their overall bone whilst going through the menopause and there are 19-year-olds with vertebral fractures.

The Irish Osteoporosis Society runs the National Osteoporosis helpline on 01 637 5050. The Osteoporosis Society assists those who are at risk, those diagnosed, those caring for those with bone loss and health professionals treating patients with bone loss.

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SOLUBLE TABLETS Paracetamol, Caffeine

FAST ACTING PAIN RELIEF

Solpa-Extra 500mg/65mg Soluble Tablets (P) contain paracetamol and caffeine. For the treatment of mild to moderate pain. Adults and children over 16 years: 1-2 tablets dissolved in water every 4-6 hours. Max 8 tablets a day. Children 12-15 years: 1 tablet dissolved in water every 4-6 hours. Max 4 tablets a day. Not suitable for children under 12 years. Contraindications: Hypersensitivity to the ingredients. Caution: Particular caution needed under certain circumstances, such as renal or hepatic impairment, chronic alcoholism and malnutrition or dehydration. Precautions needed in asthmatic patients sensitive to acetylsalicylic acid, patients on a controlled sodium diet and with rare hereditary problems of fructose intolerance. Interactions: Warfarin and other coumarins, cholestyramine, probenecid, chloramphenicol, metoclopramide, domperidone, sedatives, tranquilizers and decongestants. Pregnancy and lactation: Not recommended during pregnancy and breastfeeding. Side effects: Rare: allergies. Very rare: thrombocytopenia, anaphylaxis, bronchospasm, hepatic dysfunction, cutaneous hypersentitivity reactions, TEN, SJS, drug-induced dermatitis, sterile pyuria. Unknown: neutropenia, leucopenia, nervousness, dizziness. PA 1186/017/001. MAH: Chefaro Ireland DAC, Treasury Building, Lower Grand Canal Street, Dublin 2, Ireland. Date of preparation: 05/04/2017.

CPD Noel Stenson MPSI Self-appraisal

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Prostate cancer

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“In Ireland, prostate cancer is the second most common cancer in men, after skin cancer. Each year, over 3,300 men are diagnosed with prostate cancer here. This means that one in seven will be diagnosed with prostate cancer during their lifetime. Although there are many men with this disease, most men do not die from it.” – Irish Cancer Society Risk Factors, Symptoms and Diagnosis Incidence and risk factors As men age, their prostate gland often enlarges, which is most commonly caused by benign prostatic hyperplasia (BPH). The exact cause of BPH is unknown but it is considered part of the normal aging pattern and it has been established that there is no definite link between BPH and prostate cancer. An enlarged prostate may, however, sometimes contain areas of cancer cells. Early-stage prostate cancer is generally asymptomatic as many cancers originate

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in the posterior peripheral zone of the gland (the part furthest anatomically from the urethra). It is not until the tumour has grown large enough to put pressure on the urethra that symptoms emerge. Locally advanced prostate cancer will most commonly cause bladder obstruction with a small proportion of patients experiencing haematuria, urinary tract infections, dysuria or erectile dysfunction. In early-stage disease, these symptoms are the exception rather than the rule, with the result that early detection and diagnosis is problematic.

Prostate cancer is slow growing and can therefore be present for many years before it is detected. Men with advanced disease can present with bone pain from bony metastases and occasionally bilateral lower leg oedema from bulky lymph node metastases. Risk factors identified in prostate cancer include: n Age: Risk of prostate cancer increases after 50, although the risk increases after the age of 40 years in patients with a first degree relative with a history of prostate cancer;

n Ethnicity: The reason for such ethnic variability is unknown. The highest incidence of prostate cancer is found in African American men (1.6 times more than in white men). Japanese and Chinese men have the lowest incidence rate. Socioeconomic status appears to be unrelated to risk; n Dietary factors: No study to date has proven that diet and nutrition are either causative or preventative for the development of prostate cancer;

IPUREVIEW OCTOBER 2017

NeP Diary, an app for your Lyrica patients to support them in their Neuropathic Pain treatment journey Medication Reminders Record pain scores and functionality Appointment reminders

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Refer to Summary of Product Characteristics (SmPC) before prescribing. Presentation: Lyrica is supplied in hard capsules containing 25mg, 50mg, 75mg, 100mg, 150mg, 200mg, 225mg (for Generalised Anxiety Disorder only) or 300mg of pregabalin. Indications: Treatment of peripheral and central neuropathic pain in adults. Treatment of epilepsy, as adjunctive therapy in adults with partial seizures with or without secondary generalisation. Treatment of Generalised Anxiety Disorder (GAD) in adults. Dosage: Adults: 150 to 600mg per day, given in either two or three divided doses taken orally. Treatment may be initiated at a dose of 150mg per day and, based on individual patient response and tolerability, may be increased to 300mg per day after an interval of 3-7 days (for neuropathic pain) or 7 days (for epilepsy or GAD), the dose may be increased to 450mg per day after an additional 7 day interval (for GAD), and to a maximum dose of 600mg per day after a further 7-day interval. Treatment should be discontinued gradually over a minimum of one week. Renal impairment/ Haemodialysis: dosage adjustment necessary; see SmPC. Hepatic impairment: No dosage adjustment required. Elderly: Dosage adjustment required if impaired renal function. Children and adolescents: The safety and efficacy of Lyrica in children below the age of 12 years and in adolescents (12-17 years of age) have not been established. No data are available Contra-indications: Hypersensitivity to active substance or excipients. Warnings and precautions: There have been reports of hypersensitivity reactions, including cases of angioedema. Pregabalin should be discontinued immediately if symptoms of angioedema, such as facial, perioral, or upper airway swelling occur. Patients with galactose intolerance, the Lapp lactase deficiency or glucose-galactose malabsorption should not take Lyrica. Some diabetic patients who gain weight may require adjustment to hypoglycaemic medication. Occurrence of dizziness and somnolence could increase accidental injury (fall) in elderly patients. There have also been postmarketing reports of loss of consciousness, confusion and mental impairment. Cases of renal failure have been reported and discontinuation of pregabalin did show reversibility of this adverse effect. In controlled studies, a higher proportion of patients treated with pregabalin reported blurred vision than did patients treated with placebo which resolved in a majority of cases with continued dosing. In the clinical studies where ophthalmologic testing was conducted, the incidence of visual acuity reduction and visual field changes was greater in pregabalin-treated patients than in placebo-treated patients; the incidence of fundoscopic changes was greater in placebo-treated patients. In the postmarketing experience, visual adverse reactions have also been reported, most of which refer to transient vision loss, visual blurring or other changes of visual acuity. Discontinuation of pregabalin may result in resolution or improvement of these visual symptoms. Suicidal ideation and behaviour have been reported in patients treated with anti-epileptic agents. A meta-analysis of randomised placebo controlled trials of anti-epileptic drugs has also shown a small increased risk of suicidal ideation and behaviour. The data does not exclude the possibility of an increased risk for pregabalin. Patients should be monitored for signs of suicidal ideation and behaviours and appropriate treatment should be considered. Patients (and caregivers of patients) should be advised to seek medical advice should signs of suicidal ideation or behaviour emerge. Insufficient data for withdrawal of concomitant anti-epileptic medication, once seizure control with adjunctive Lyrica has been reached, in order to reach monotherapy with Lyrica. After discontinuation of short and long-term treatment, withdrawal symptoms have been observed in some patients; insomnia, headache, nausea, anxiety, diarrhoea, flu syndrome, nervousness, depression, pain, convulsion, hyperhidrosis and dizziness, suggestive of physical dependence. The patient should be informed about this at the start of the treatment. Convulsions (including status epilepticus and grand mal convulsions) may occur during treatment and shortly after withdrawal. Concerning discontinuation of long-term treatment, data suggest that the incidence and severity of withdrawal symptoms may be dose-related. (see side effects). There have been postmarketing reports of congestive heart failure in some patients receiving pregabalin. These were mostly elderly, cardiovascular compromised patients who received treatment for a neuropathic indication. Pregabalin should be used with caution in these patients. Discontinuation of pregabalin may resolve the reaction. There have been postmarketing reports of reduced lower gastrointestinal tract function when pregabalin and opiates are co-prescribed. Measures to prevent constipation may be considered. Cases of misuse, abuse and dependence have been reported (exercise caution in patients with a history of substance abuse and monitor patients for symptoms of pregabalin misuse, abuse or dependence (development of tolerance, dose escalation, drugseeking behaviour have been reported)). Cases of encephalopathy have also been reported (take care in patients with related underlying conditions). Ability to drive and use machines: May affect ability to drive or operate machinery. Interactions: Pregabalin appears to be additive in the impairment of cognitive and gross motor function caused by oxycodone and may potentiate the effects of ethanol and lorazepam. In the postmarketing experience, there are reports of respiratory failure and coma in patients taking pregabalin and other central nervous system depressant medications. Pregnancy and lactation: Lyrica should not be used during pregnancy unless benefit outweighs risk. Effective contraception must be used in women of childbearing potential. Pregabalin is excreted into human milk. A decision must be made whether to discontinue breastfeeding or to discontinue pregabalin therapy taking into account the benefit of breast-feeding for the child and the benefit of therapy for the woman. Side effects: Adverse reactions during clinical trials were usually mild to moderate. Most commonly (>1/10) reported side effects in placebo-controlled, double-blind studies were somnolence, dizziness and headache. Commonly (>1/100,