In the Roman world, the most infamous of the Ides fell on the day in 44 BC when the emperor Julius Caesar, having summoned the Senate but ignored the advice of a seer, met a bloody end in the Theatre of Pompey. Since then, the Ides has been a metaphor for impending doom. And there is indeed something of it in the continuing row between community chemists, the HSE and the Minister for Health which, though not threatening murder and mayhem, may yet trigger a mass exodus from the GMS. It goes without saying that any situation which could hit the welfare of patients as hard as the livelihoods of pharmacists must be avoided. In the normal course of events it probably would be, if there was any prospect of a deal that would satisfy all sides. But right now there isn’t, and the pharmacists’ fear is that what is being demanded of them is not compromise but capitulation.
Throughout this controversy, the pharmaceutical wholesalers have stayed silent, content it seems to hold the coat for the chemists, but not to throw a punch themselves.
The HSE continues to rely on what it believes are cast-iron assurances from the wholesalers that the retailers will not have to pay more than they are reimbursed. Yet the message which is apparently being given by the middlemen to community chemists is entirely different; in short, it is that they don’t intend to take private pain for public gain.
Last Wednesday, over 1,000 chemists packed the ballroom in Dublin’s Jurys Hotel. The scale of the turnout was twice what organisers had expected and many who travelled had to stay in the corridor outside, listening to the drama and militancy unfolding inside.
This meeting marked a high point for a campaign that has become increasingly sophisticated. While the chemists have often misunderstood the nature of the price cuts – and made some horrible tactical choices, like the decision by some to withdraw from the methadone treatment scheme – they have never lost sight of the potential consequences of the plan, which could become apparent very quickly if the wholesalers really do refuse to give.
It’s doubtful if there are many – or any – who will sign the proposed interim contract, which includes a flat dispensing fee that appears to be well short of what the sector says it needs to provide the current service, not to mention any of the other areas that could be included in a new contract.
The Pharmacy Regulator is already flagging a plethora of services where pharmacy could do more to ease the pressure elsewhere, including testing for cholesterol, treating minor ailments, and managing patients with stable long-term medical conditions e.g. heart and respiratory illnesses.
Although this review group won’t report for another three months, its conclusions – or the thrust of its likely recommendations – will have to inform the framework of a new pharmacy contract. In an ideal world, its proposals would dovetail neatly into contract negotiations, and the whole deal would be done and dusted before the summer. The standoff between the HSE and Irish Pharmaceutical Union means it’s virtually impossible to start these talks.
Another option for the chemists would be to accept the new interim flat fee and contract, pray the wholesalers will take the hit on prices, and hope that a higher fee will be approved in a few months’ time with the inclusion of new services and extra rewards in a better contract. Judging by the mood of the chemists, that option looks too vague to be widely accepted.
And then there’s the nuclear option – a sudden, mass withdrawal from the GMS – which would leave everyone with the worst of all worlds. The chemists say this is the last thing they want, but they won’t discount the possibility if there isn’t a credible mechanism put in place to resolve the issues of remuneration, representation and reimbursement.
It’s difficult to see how substantive talks can get under way – much less succeed – given the chemists’ concerns that significant price cuts, which were intended for the wholesalers, could end up hitting them instead.
Serious drop in income
And as long as they see the potential for a serious drop in their incomes as a result, there is no prospect whatever of them coming to the table to negotiate, and every possibility of them leaving the GMS.
Although the high price of prescription medicines is clearly unfair to consumers and taxpayers and must be addressed, putting hundreds of small pharmacies under needless financial pressure is not acceptable, either.
The template which it was hoped could be used to set fees for those supplying health services while staying on the right side of the Competition Act is clearly in trouble. It is not too late to find a new way forward.