The tendency of any military is always to fight the last war. The biggest danger for the community pharmacy sector is that it will allow the row over reimbursement rates for medicines it dispenses under the community drug schemes to cloud its judgment on what it can and should achieve in a new pharmacy contract.
Unless the Courts rule that there was no legal basis for changing the old reimbursement rules, new ones are certain to stick. If the chemists have any sense, they will now start to focus on getting a new contract which, on the one hand, brings incomes back to where they were before the drugs pricing regime was turned on its head and, on the other, provides a contractual basis and a fair price for all the new services they can deliver.
This is not just a question of a profession getting a good deal; fundamentally, it’s about reshaping primary care services to work much better. The settlement of sorts between the Health Service Executive and the Irish Pharmaceutical Union means the union has now been recognised as the chemists’ representative body for the purpose of contract negotiations, which will include face-to-face discussion of alternative reimbursement models.
This has been the big breakthrough and it gives the process initiated under the leadership of Mr Sean Dorgan, former head of the Industrial Development Agency, vital breathing space. The fact that his group is taking the trouble to discover the true costs of delivering a community pharmacy service, and that it is apparently open to considering alternative reimbursement models, has led to a certain confidence in the sector that the final outcome on pricing will be fairer.
The row over reimbursement has delayed but not derailed the requirement for a new contract. This should have clear principles and tangible services. In February, the HSE asked for submissions on the non-fee elements of a revised contract. It announced that new services could be bolted onto the core dispensing role, and invited views for a more detailed specification of service delivery (presumably this could mean things like longer opening hours and direct delivery of prescriptions by the chemists themselves to house-bound patients), a stronger quality-assurance focus and improved governance.
Good deal for chemists
At a high level, this framework opens the way to a good deal for chemists. At a deeper level, it provides them with a real chance to reshape primary care services. At a minimum, there should be a set of general principles included in the contractual framework to guarantee that service delivery is appropriate to local needs and conditions, to maintain a focus on quality assurance, and to ensure that governance respects and reflects the independence of these contractors.Firstly, the chemists should be rewarded for the range and quality of services they provide, rather than the volume of medicines they dispense.
Secondly, gain sharing should be introduced to support service innovation and cost containment. The latter requires a particular change in the law to empower the chemists to dispense a generic rather than a branded drug, unless there are compelling patient or public interest reasons in favour of the branded drug or issues around bioavailability. Switching to generics where feasible could effect real savings year-on-year on the escalating drugs bill.
Thirdly, as experts in the safe use of medicines, the chemists should have appropriate prescribing powers but parallel obligations to inform and educate the patient, particularly where there may be an interaction, however mild, with a prescription medicine which the patient may currently be taking. Fourthly, patients should have a fundamental right to choose where they have their prescriptions dispensed.
In other words, the terms and fees in a new contract should not be so onerous for the chemist that patients end up travelling to shops in distant towns because the service they used to get locally has been made uneconomic by the contract.
This could happen, for example, if a chemist in a small village was forced to keep the same opening hours that would suit a colleague in a nearby town or city for their own business reasons, simply because the funder wanted a one-size-fits-all policy.
Fifthly, the scale of fees should reflect the reasonable costs of delivering an evolving dispensing model (which increasingly includes phased dispensing for older people and people with mental health conditions), as well as providing the various new clinical services which the evidence base says can be provided safely and effectively in this care setting. There should be an in-built mechanism whereby fees are reviewed every three to five years.
Finally, there should be an arbitration process for resolving disputes around fees, discipline, and the suspension or termination of a contract.