Organ donation: a new model for Ireland?

A surge in the efforts of hospital staff to approach the families of recently deceased patients about donating their organs is being credited with a dramatic increase in the number of donor organs and transplantations so far this year.

We are a generous nation; new data from the European Commission reveal the willingness of 64% of Irish people to donate their organs immediately after death, and almost 60% would agree to donate an organ from a deceased close family member, if they were asked in a hospital.

But this ultimate act of charity could be lost without the timely and sensitive intervention of fully trained organ donor co-ordinators in hospitals around the country.

That’s the message from a recent European Commission (EC) workshop on organ donation and transplantation in Brussels, during which the heads of transplantation organisations in Europe alongside organ recipients expounded the importance of streamlining national donor and transplant systems to maximise organ availability and save more lives.

Croatia’s remarkable achievements in this regard were held aloft as an example for Ireland and other countries whose donation and transplantation rates in 2010 were well below the EU average.

A country similar in size to Ireland, Croatia managed to transform its national transplant system, climbing from 14th to 2nd place in Europe for deceased organ donations, just behind Spain, in only one year.

In 2010, Croatia’s donor numbers exploded, increasing by an astonishing 64.9%, and the total number of organs transplanted from deceased donors increased by 54%. This remarkable result has been largely attributed to Croatia having placed trained donor coordinators in all their major hospitals and offering financial incentives to donor hospitals.

This new system is based on a model pioneered in Spain in the 1990s, which has more than tripled organ donor numbers and elevated Spain to the world’s highest ranking country for organ donations at 32 per million of population last year.

By sharp comparison, Ireland fell to 22nd place in Europe in 2010 because of a drastic drop in deceased donations of over one third in 12 months from 90 to 58 deceased donors.

However, the level of deceased donations so far this year has already surpassed 2010 figures. Thanks to the generosity of 77 deceased donors and their families willingness to donate their organs, there have been 137 kidney transplants, 49 liver transplants, 6 pancreas transplants, 4 heart transplants, and 8 lung transplant operations. This year will also mark a record year for living transplantation with 24 living kidney transplants carried out, as of mid-October.

With the establishment of Ireland’s transplant authority - the HSE National Organ Donation and Transplant Office - in March this year, and a report of the first external review of our organ donation and transplantation services expected by the end of November, it appears that Ireland is taking its obligations under a new European Union (EU) Directive on Organ Transplantation very seriously.

According to the new rules, which will be transposed into national law by July 2012, all EU member states must have a national authority responsible for maintaining quality and safety standards for organs intended for transplantation. The first undertaking by Professor Jim Egan when he was appointed Director of the Organ Donation and Transplant Office in March this year was to convene a National Transplant advisory group. He also instigated the first external expert review of Ireland’s organ transplantation service in October.

Professor Jim Egan

Prof Egan told Modern Medicine of Ireland that his office, in partnership with the Intensive Care Society of Ireland and the National Organ Procurement Office, are in talks to further develop a network of donor coordinators in hospital Intensive Care Units (ICUs) around the country, which will “bring Ireland to a level comparable to international practice”.

He indicated that these individuals would be drawn from “existing voluntary expertise” at a medical and nursing level. Under discussion at the moment are the number of donor co-ordinators to be appointed nationally, in which hospitals they will be based, and what protocols and training will be appropriate for these crucial and challenging posts.

Expanding the network of hospital donor co-ordinators is a key priority in the new EU Directive and accompanying 10-point action plan. It is considered the first step in developing a proactive donor detection programme and optimising the entire process of organ donation.

Whether these individuals should have a medical, nursing or psychology background is under debate. For example, in the UK, the majority of donor transplant co-ordinators are registered nurses that have experience in critical care. Mr Mark Murphy, Chief Executive of the Irish Kidney Association, maintains that the donor co-ordinator would benefit from a background in bereavement counselling. In Spain, more than half of the donor co-ordinators are doctors.

“Our philosophy is that the transplant co-ordinator should be a doctor and should be based in the hospital,” Dr Rafael Matesanz, who is Director of Spain’s hugely successful National Transplant Organisation (ONT), told Modern Medicine of Ireland.

Dr Rafael Matesanz

“I know there are many countries who have a different philosophy, some have nurses, some have social workers or psychologists, but our philosophy in this, and what we tell all the countries who have asked us how do you organise this, is that the system which works is to have an in-house medical coordinator.”

He continued: “The European Directive requires all 27 countries to have a competence authority to be in charge of organ donation and to guarantee quality and safety of transplantation. But in fact this competence authority should be responsible for creating a system of co-ordinators, which is the system in place in Spain, in Belgium, in France, in Italy, in all of the countries that have been improving organ donation levels.”

Dr Matesanz outlined the chain of organ donation and transplantation, which begins with donor detection and moves systematically on to donor maintenance, brain death diagnosis, family consent, local and organisational factors, procurement and, finally, transplant. He stressed that the two weakest links in this chain are donor detection and family consent.

“Approaching the family is probably the key point in this process and is a very sensitive topic. When the family is approached they can say yes or they can say no, the difference this makes is that many people can be transplanted or they cannot. And the decision they make relies primarily on the skill of the person who makes the approach about organ donation,” he told delegates at the workshop in Brussels.

Meeting families’ support needs during this traumatic time is an obligation and a challenge for critical care staff. Results of research spanning over 30 years on the effects of families’ hospital experiences on their decisions about organ donation for a relative have generated compelling evidence regarding the significance of families’ satisfaction with hospital care, their understanding of brain death, and the timing of the donation request.

Some of the issues raised include the importance of families’ being given time to bring up concerns with staff, receiving clear information about their relatives’ condition and the organ donation process, not being pressured to make a decision, and being shown respect and compassion.

Dr Matesanz advised Europe’s cash-strapped national health authorities that focusing on the management of the donor/transplant process at hospital, regional and national level would be the most effective use of resources.

“It is unwise to have too much confidence in direct publicity campaigns aimed at the general population,” he cautioned. “Apart from some anecdotal observations, there is no evidence in medical literature documenting that direct publicity campaigns are really able to influence positively the attitude of the public to organ donation.”

He illustrated this point by highlighting two national polls – conducted 13 years apart – that gauged the attitudes of the Spanish population towards organ donation. Between 1993 and 2006, despite ongoing organ donor awareness campaigns, the number of people willing to donate their organs remained static. However, the number of actual donors during this period more than tripled from 550 to 1,606, due to a restructuring of the Spanish organ donor and transplant system.

Ms Charlotte Möller, coordinator for donation and transplantation at the National Board of Health and Welfare in Sweden, offered a qualified agreement on this point, arguing that expensive “blanket” organ donor publicity campaigns are not effective but a carefully devised and focused campaign does work and is much cheaper by comparison.

She explained how, over a three year period, the Swedish government spent €2.7 million on TV, radio and newspapers campaigns to raise people’s awareness about organ donation. The outcome was only a slight increase in the national donor registry numbers and donor frequency.

So, a new communications strategy was developed in 2010, culminating in a weeklong awareness campaign in October that year. A special team was assembled to work with the new strategy; a central web portal was set up; online social networks were utilised; media kits were developed, focus was placed on patient stories and their families, along with other initiatives.

The donor awareness week resulted in a blitz of TV and radio interviews, more than 100 articles and massive activity on Facebook, Twitter and Blogs. By the close of the campaign, the number of people who registered as an organ donor rose by over 25%. The total cost was only €70,000.

Dr Axel Rahmel

Dr Axel Rahmel, Director of Eurotransplant International Foundation, based in Leiden, The Netherlands, emphasised to the workshop the importance of a transparent organ allocation system, based on sound medical and ethical allocation principles, in addressing the needs of patients on the waiting list, making best use of the available donor organs, and increasing public trust of transplantation services.

While main barrier to successful organ transplantation is a serious shortage of donated organs, Dr Rahmel was confident that organ donation could be improved by a well-organised and structured approach.

“A perfect example, Croatia has achieved another increase in organ donation again this year. I assume Croatia will be the European champion in organ donation in 2011 and that was from starting with a donation rate below 10 per million population a few years ago. So what did they do? They adopted some of the Spanish model and put [donor] co-ordinators in the hospitals, focused on organ transplantation and introduced legislation on presumed consent,” he said.

There is currently no legislative framework in Ireland governing the use of or consent relating to the donation of organs, in contrast with most of Europe. At present, a person has to indicate their willingness to donate their organs by carrying a donor card. The Programme for Government promises to legislate for an opt-out system, which assumes everyone is an organ donor unless they have expressed otherwise.

During the lengthy public consultation and preparation of a Human Tissue Bill in 2009 and 2010, the Department of Health explored the case for ‘opt-in’, ‘opt-out’ and ‘mandated choice’ systems of consent for organ donation. While legislation was expected to be published soon after, nothing happened. Health Minister Dr James Reilly told the Dail in October that he intended to “bring legislative proposals for a Human Tissue Bill to Government early next year”.

The new EU Directive acknowledges that several models of consent to donation coexist across Europe and it does not recommend the adoption of any particular model. Mr Mark Murphy, who represented the European Kidney Patients' Federation at the workshop in Brussels, stated that legislating for one donor consent system or another was immaterial.

“None of this directly impacts on the level of organs donated in a country,” he said. “What makes the different is how you approach a grieving family in the hospital about donating a loved one’s organs. The right to say yes or no ultimately rests with family members and no one in a hospital is going to challenge them on that issue, regardless of the legal framework.

“We have to recognise that this is a very difficult time for families and we need specially trained donor co-ordinators in the hospitals who can approach them sensitively, listening to them, answering their questions and explaining the process. That will make the difference.”

Pharmacists Crucial In Chronic Disease Management

Chronic diseases – such as heart disease, stroke, COPD, and diabetes – are among the most prevalent, costly, and preventable of all health problems. And they’re on the rise in Ireland, in tandem with our ageing population and unhealthy lifestyle choices.

The Institute of Public Health in Ireland (IPH) forecasts a 40% increase in the number of people living with these chronic conditions in the Republic of Ireland by 2020 - that’s more than 1.7 million people - making the prevention and management of chronic diseases the greatest actual and future challenge to our healthcare system.

At present, for many individuals with a chronic disease, care is reactive, sporadic, and usually occurs within the costly hospital system. In fact, chronic diseases account for a massive 80% of all healthcare costs. Both government and individual caregivers recognise that this is unsustainable. The axis of care must shift and a new approach developed that puts chronic disease management programmes in a central position to prevent, treat and delay the onset of complications for those with a chronic condition.

The fact that people with chronic conditions managed by medication have more contact with community pharmacists than any other healthcare professional, places pharmacists in an ideal position to detect early changes in condition and identify at-risk patients well before they reach the hospital revolving door.

“There is so much benefit to be had by involving the pharmacist in the management of a patient’s chronic disease, whether it’s asthma, diabetes or a heart condition. We know these patients, some of them for many, many years; we see them every time they get a prescription filled. There are opportunities for health screening, medicines management, health promotion, and incentive-based self-management. We’re a logical part of the solution,” said Professor Peter Weedle, adjunct Professor of Clinical Practice at the School of Pharmacy, University College Cork (UCC) and a community pharmacist from Mallow, Co Cork with over 25 years’ experience.

“In Ireland, we are clogging up our hospitals with people who have chronic diseases. We knew they had a chronic disease and they were being treated for their chronic disease and yet they end up in hospital because we have failed or they have failed to manage their condition correctly.”

Prof Weedle has long maintained that pharmacists can make a significant impact on critical areas of patient care. He published a paper in the British Journal of Pharmacy Practice in 1983 in which he defined pharmaceutical care. “What we were saying back then was that pharmacists need to start talking about pharmaceutical care; not talking about medicines, not about medicine management or medicine use review, but talking about patients. In the same way you talk about medical care or nursing care, we needed to start talking about pharmaceutical care.”

“That was nearly 30 years ago and not much has changed in the interim, but hopefully, with the establishment last year of the HSE’s new Clinical Care Programmes under the Clinical Strategy and Programmes Directorate (CSPD), led by Dr Barry White, we have an opportunity to explore how pharmaceutical care can fit into and benefit a new integrated approach to acute and chronic disease management,” he said.

A panel of pharmacists with an interest and expertise in chronic diseases was recently selected to participate in the chronic disease CSPD Clinical Care Programmes, which include heart failure, stroke, COPD, asthma, diabetes and care of the elderly.

Professor Peter Weedle

Prof Weedle, who was involved in the selection process in his capacity as Chairperson of the National Pharmacy Reference Group (NPFG), remarked: “We got a phenomenal and enthusiastic response from the profession of pharmacy when we looked for expressions of interest to participate in these programmes. Almost immediately we had about 70 or 80 people volunteer to get involved in the various programmes.

“It’s very exciting to see the various experts, be they consultants, GPs, nurses, pharmacists, physiotherapists, dieticians, all meeting together and looking at what are the gold standards for the treatment of any particular chronic disease, and how these complimentary professions can work together. Taking one example, heart failure, there are new and compelling data which suggest that an integrated, collaborative approach to care involving GPs and pharmacists can improve the long-term outcomes for patients. I believe this is a very exciting development for patients and our profession; it’s a natural evolution and a golden opportunity just waiting to be tapped.”

The reality is that people with chronic conditions managed by medication have more contact with community pharmacists than any other healthcare professional.  Poor adherence to medicines affects 30-50% of patients and often it is the pharmacist who directly observes this. Consequently, community pharmacists are well placed to monitor the patient’s medication adherence, encourage self-management, and also detect early warning signs and changes in the person’s medical condition.

“In an ideal world, the pharmacist has a role in at least three important areas of chronic disease management. First, pharmacists see a wider group of patients to GPs and hospital doctors and can screen the population widely for undiagnosed chronic disease. Secondly, pharmacist can carry out therapeutic drug monitoring and self-care,  checking that the patient’s condition is properly controlled. For example, a patient with diabetes, who is monitoring their blood glucose levels on a daily basis and recording that information, could bring their self-care records into the pharmacy with their prescription for repeating on a monthly basis. Thirdly, because several chronic diseases tend to co-exist in the same patients, pharmacists can help identify important pharmaceutical care issues, with complex drug-drug and drug-disease interactions a growing problem.”

“The pharmacists can chat with the patient, review their records and condition, and if everything is fine the prescription is dispensed. If not, they can be referred back to their GP. But, at the moment, the pharmacist cannot tell if the patient is managing their condition optimally and could be repeating the prescription for six months when in fact the patient really needs to see their doctor to have their treatment reviewed.”

“This is just one example. Specialist training is being developed for pharmacists, who are interested in running clinics for a specific condition, at which patients can be monitored, their medication reviewed, and perhaps running group education sessions. This will be carried out, where possible, in conjunction with the CSPD programmes. It too early to say how the CSPD programmes will work, but the potential is vast,” Prof Weedle stressed.

Effective medical therapy is a key factor in good chronic disease management programmes. Half of all people with chronic conditions fail to take their medicines properly and 10% of hospitalisations may be due to older people’s inability to manage drug therapy.

The rates of non-adherence to prescription medication therapy have remained stagnant over the past three decades and recent research has shown that as many as 40% of patients still do not adhere to their treatment regimens and up to 20% of all new prescriptions go unfilled.

Medication non-adherence is a problem that applies to all chronic diseases, diminishing the ability to treat diabetes, heart disease, cancer, asthma and many other conditions, and resulting in suffering, sub-optimal utilisation of healthcare resources and even death.

“If we want to improve patient adherence to prescription medication, it is clearly imperative that we involve pharmacists as part of a multi-disciplinary approach to patient care. Recent Irish work has shown that non-persistence of vital medicines affects 30% of a well-educated heart failure population and is associated with worse outcome and increased healthcare costs. This highlights the importance of regular, on-going, professional management of adherence issues.”

“We’ve seen situations of medication being returned, unused - not in small carrier bags but in black bin bags - when a patient has died. For example, a few years ago a lady’s family brought back her medicines. We were able to take out a product she received regularly, used in the treatment of osteoporosis, and place all 24 unopened packets in the order in which they had been dispensed. None were missing. She had not taken them in two years yet was still getting the prescription.The cost of those medicines was €1,200. Not only was this money wasted but the patient’s condition was going untreated and unmonitored,” Prof Weedle pointed out.

He maintained that chronic disease management in community pharmacy deals primarily with control and prevention. Medication compliance, monitoring of disease parameters and complications, health education, lifestyle modification advice and identifying situations to seek help from health professionals, are key components in the management of chronic diseases in community pharmacy. A pivotal element in this partnership is pharmacist-led patient self-management.

“I’m a great believer in self care,” said Prof Weedle. “The patient needs to take responsibility for their own health, their own treatment. However, the emerging evidence suggests that regular, on-going professional encouragement and coaching is key. The bottom line is our population is aging and we have to accept the growing chronic disease burden.  But having a disease does not mean you cannot live long and well. “

“Provided the patients themselves are coping well, we should get away from this idea that only health professionals can manage their condition. The patients themselves should be taking an active role in controlling their disease and we should be helping, coaching, advising the patient in the management of their own chronic care.”

With the regulatory framework in place, by way of the Pharmacy Act 2007, the role of pharmacy is set to expand exponentially, enhancing pharmacists' responsibilities in the delivery of health care and disease management.

In order to facilitate this pharmacist-led approach and integrate the pharmacist in the multi-disciplinary care of patients with chronic diseases, it may be appropriate to allow pharmacists access to electronic health records, as well as deregulation of more prescription-only medicines to pharmacy-only medicines, as seen recently with the emergency hormonal contraception.

These are all details that will be teased out over the coming months by members of the clinical care programmes for chronic diseases, and their deliberations will have widespread implications for the future training and practice of pharmacy in Ireland.

“This is an ongoing process; there won’t be an official launch date for pharmacy’s involvement in the management of chronic diseases, it will happen gradually. It’s happening now and it’s gathering pace all the time,” said Prof Weedle.

“As the clinical programmes report we will start to see how the national parameters by which we treat a particular disease category – the gold standards - will change and how this will impact on the role of the pharmacist in the management of chronic diseases in the community.”

“I believe when we look back in perhaps two years from now we will see that we’ve implemented a huge range of initiatives in pharmacy in this regard, including possibly legislative change where time-limits on prescriptions are concerned. The potential for pharmacy is huge, as are the benefits for the individual patient and our health service as a whole. These are very exciting times don’t you think?”

On the rise: Chronic diseases in Ireland

High blood pressure

In 2007 nearly 852,000 adults (25.1%) had high blood pressure. By 2020 this is expected to rise to over 1,192,000 people - an additional 341,000 adults (a 40% increase in less than 15 years).

Coronary Heart Disease (CHD)

In 2007 nearly 131,000 adults (3.8%) had ever had a Coronary Heart Disease (CHD, angina and heart attack). By 2020 this is expected to rise to over 195,000 people - an additional 65,000 people (a 50% increase in less than 15 years).

Stroke

In 2007 almost 59,000 adults (1.7%) have ever had a stroke. By 2020 this is expected to rise to almost 87,000 people – an additional 28,000 adults (an increase of 48% in less than 15 years).

Diabetes (Type 1 and Type 2 combined)

In 2007 nearly 144,000 adults (4.5%) have diabetes (Type 1 and Type 2 combined). By 2020 this is expected to rise to over 233,000 an additional 89,000 adults – (a 62% increase in less than 15 years).

Source: Institute of Public Health in Ireland

A Prescription for Change

The underutilised profession of pharmacy has become the sleeping beauty of our health services but not for much longer. 

Historic changes are underway that promise to awaken a new dynamic in pharmacy practice in Ireland, enabling pharmacists to reach their full potential in delivering an enhanced range of services to patients as part of inter-professional multi-disciplinary healthcare teams.

New legislation has provided scaffolding around which the profession recently commenced a major restructuring of pharmacy education and training in Ireland, which will lead to a significant and major expansion of the role of pharmacy practice.

The scope of untapped potential in the profession is extensive, ranging from health screening and vaccinations to pharmacist prescribing and clinical specialisation.

And pharmacists around the country are keen to embrace this new direction, according to the Pharmaceutical Society of Ireland (PSI), the pharmacy regulator. A recent PSI Study of Community Pharmacy Practice in Ireland that found most pharmacists want to provide new and enhanced services, such as lung capacity screening, sexual health services and structured medicine use reviews. They told researchers that they feel pharmacy is under-valued and under appreciated in current healthcare structures.

The springboard from which the profession is launching itself into a bright new future is the Pharmacy Act 2007. Replacing legislation more than 130 years old, the new Pharmacy Act provides modern and robust regulations that will make the profession more transparent, patient-centred, and focused on patient safety.

A key aspect is the introduction of mandatory continuing professional development (CPD) for pharmacists in Ireland. Currently, in order to be accepted for continued registration, all pharmacists now sign a declaration on an annual basis that they will maintain competency and continue to bring new knowledge and skills to their practice.

In line with the recommendations contained in its Review of International CPD models, the PSI is currently implementing a new system of mandatory CPD for pharmacists.

Kate O’Flaherty, PSI Acting Head of Pharmacy Practice Development, explained that this new CPD system is not based on a traditional points system or accumulation of contact hours. Instead all pharmacists will be encouraged to adopt a more reflective approach to learning and to identify their own learning and development needs based on the skills and competencies required for their particular professional practice.

“Our new CPD model is largely based on a model that has been in place for the last 13 years in Ontario, Canada, for pharmacists. Patient safety is at its core, and it’s a self-reflective peer-supported model. We are currently developing a CPD portfolio, which will be most likely an online portfolio that will serve as a template for pharmacists to help them assess their learning needs and enable them to record, evaluate and demonstrate their professional development.”

The new CPD system will also take into account the many types of learning in which pharmacists can engage in order to progress their professional development. These range from Informal Learning, such as practical, “on-the-job” learning from experience that traditionally does not lead to certification but enhances the individual’s professional knowledge and skills; through to Formal Learning by participation in quality-assured, structured programmes of education training.

“We’re also developing a competency framework for pharmacists which will help with, for example, communication and consultation skills. There are patient consultation areas in all pharmacies now, so possibly many pharmacists will feel they need to develop their communication and consultation skills to maximise the benefits to patients of consultations, and learn how to deal with new and challenging scenarios. They may need new skills or to develop the skills that they already have,” said Kate.

“Another aspect of our CPD model is the peer support and peer review system. Pulling this all together is the imminent establishment of the first Institute of Pharmacy in Ireland. The various medical specialties all have their own colleges or institutes, such as the ICGP or the College of Obstetrics and Gynaecology. Similarly, the Institute of Pharmacy will manage our new CPD system,  a quality assurance process and an assessment process that would be based for the most part on peer assessment.

“The exciting potential of this new Institute is that it will also offer a platform for the development of specialisation in pharmacy. For example, in other countries where this has been developed you would have consultant pharmacists in oncology or cardiology, and they would be part of a wider multi disciplinary healthcare team. Many of those pharmacists would also have specialist prescriptive authority.”

This is a ground-up restructuring initiative for the PSI, starting with an overhaul of the current undergraduate programme, which has long been a four-year pharmacy degree with a further one-year pre-registration training period. The new education model that will replace the old system, possibly as early as 2012, is a five-year integrated Masters programme, which allows pharmacy students to contextualise theory and knowledge in structured placements in a variety of pharmacy fields.

“The students will be regularly placed on work experience in pharmacies, whether it’s in the community or hospital or pharmaceutical industry, which will make what they’re learning in the lecture or the lab more relevant to them. It’s much more integrated and they get to experience what it’s like to work with real patients and as part of a multi-professional healthcare team.

“This model will also create new roles for a lot of established pharmacists who, under the new system, will become teacher practitioners. As well as running a pharmacy and looking after patients, their pharmacy will become a teaching pharmacy; they will take on student pharmacists for on-the-job learning,” said Kate.

A new Tutor Training and Accreditation Programme (TTAP) was developed in 2010 by the Royal College of Surgeons in Ireland (RCSI) on behalf of the PSI to train and accredit tutor pharmacists who oversee the workplace training of pharmacy interns.

November of the same year saw the first cohort of 139 students graduate from the inaugural Masters-level MPharm programme, delivered by the RCSI, marking the first significant milestone of the education reform agenda.

“What’s exciting is that this initial masters programme gave us a start on developing the curriculum for the new integrated five-year masters so that it incorporates new emerging trends and the expanding role in pharmacy. It brings Irish pharmacy in line with international best practice.

“For example, all of the new Masters’ graduates are trained in vaccination skills and they all participated in an inter professional prescribing sciences module alongside medical students, which was not on the curriculum previously.”

Pharmacists are playing an increasing role in direct patient care

The PSI, through its Pharmacy Ireland 2020 initiative, is also encouraging and facilitating greater involvement of pharmacists in the delivery of integrated health services in the community and has established an expert National Pharmacy Reference Group to progress this agenda. A key initiative is to support pharmacy engagement in the work of the HSE Clinical Stategies and Programmes Directorate on implementing new clinical and disease management programmes in pharmacy.

This desire to actively engage more with local multi-professional groups in the care of patients was voiced by 94.6% of pharmacists who responded to the PSI Study of Community Pharmacy Practice in Ireland.

Many respondents felt that the pharmacist is currently underutilised and that there is potential to expand the role of pharmacy in healthcare services to patients. Screening and diagnostic services, medicine use reviews, minor ailment schemes, and vaccinations, were some of the suggestions for the pharmacist to contribute more to patient care.

“For a lot of people, the first contact they have with the health service per se is when they walk into their local pharmacy looking for advice and information. It’s very important that pharmacy is linked with the rest of the health service, fully participating in national public health initiatives, and maintaining close links with multidisciplinary care teams,” observed Kate.

Arising from the recent reclassification by the Irish Medicines of the formerly prescription-only emergency contraceptive pill which is now available directly from pharmacists without a prescription, she envisaged the potentially more medicines could be considered for switching from prescription control so they can be accessed from a pharmacist.

“In other countries there are more nedicines available through pharmacists, essentially the patient will be getting their medication from a different healthcare professional who is perfectly competent, and has the appropriate consultation environment and training,” she pointed out.

In the UK and other countries, medicines such as oral fluconazole for thrush in women; some of the triptans for migraine; statins; low dose aspirin, and certain antibiotics are available from pharmacists.

In addition, more than 50 Boots pharmacies nationwide provided a flu vaccination service last winter, with other pharmacies expected to follow in the coming year. In countries where seasonal flu vaccinations are available in pharmacies, uptake levels have increased by up to 50%.

“Why stop with the flu vaccination? Pharmacy could link in with other public health vaccinations, such as the cervical cancer vaccine. Pharmacists need to be integrated more into the greater wider health service. It’s not the pharmacist or the GP working in isolation, we should be working together to capture all patients who need vaccinations.”

And Kate added: “Up to 2007, when the new pharmacy Act was introduced, the argument against pharmacists vaccinating or making the morning after pill available in pharmacies, or pharmacist prescribing was that we didn’t have the regulatory framework to protect the public. There was no fitness to practise if anything went wrong; you didn’t have robust regulations that would give guidance to pharmacies; and we didn’t have mandatory CPD so there was no way of assuring that pharmacists were continually ensuring their skills were up to date.

“But now we have all of those requirements and safeguards in place or imminent, those arguments against expanding the role of pharmacists are essentially gone. Our future pharmacy graduates are going to be trained to the highest international standards. All of the markers are in place - the regulatory framework, new education and training initiatives, and the appetite to expand our role in the community - the catalyst for this development to take off in a big way is here and ultimately patients and the health system will benefit.”