Tuesday, December 11, 2012

Patients and pharmacists feeling the pinch

Reliance on community pharmacists for health advice and help meeting the expense of medicines is an ever-growing phenomenon around the country as the recession vice tightens and many struggle to afford basic healthcare.
More than 90% of pharmacists have attested to a huge surge in the number of people seeking help for minor health ailments, advice and support on obesity and smoking cessation, and heath screening services, since the start of the recession.
Pharmacists say they are also increasingly offering flexible payment options to patients, who are finding it hard to meet the cost of private prescriptions. Many fear that cash-strapped patients may cut back or stop taking their medication altogether.
Of course, the pharmacy sector itself is not immune to the ongoing recession and ever-shrinking income. Not only have community pharmacists reported that the bottom has fallen out of front-of-counter sales in recent times, they are also coping with massive direct and indirect reductions to their payments from the State.
The Irish Pharmacy Union (IPU) has recorded job losses of well over 1,600 staff in the pharmacy sector in less than two years, with a rising number of small independent pharmacies closing their doors permanently.
“We’re all being squeezed, that’s the reality,” says John Gleeson, a pharmacist on the outskirts of Limerick city. “Most definitely I’m seeing more and more people who are not able to afford their medication, including people with chronic conditions such as asthma or heart disease, who are not eligible for the medical card. My reaction to that, and every pharmacist’s reaction to that, is total horror.”
John tries to accommodate people in financial difficulty with easy payment plans but inevitably there are people who simply do not have the money.
“We try to help our customers in whatever way we can so that they will be able to get the medicine they obviously need. We can set up weekly instalments, or give them a bit of credit to tide them over. We do everything in our power to make sure that people still receive their medication, and yes, sometimes that means we don’t get paid,” he adds.
John runs a suburban city pharmacy, two miles outside Limerick, in a predominantly middle class area, which he says has been financially hard-hit by the recession. Over the past two years he has noticed a significant and worrying shift in purchasing patterns at his pharmacy that reflect the difficulties being experienced in the local community.
“There certainly has been an increase in people coming to me for their OTC cold and flu remedies because they’re self-treating; it’s the cheapest option. I’m also seeing less prescription business, particularly less one-off prescription business, and it’s not just because they can’t afford the price of the tablets, they often can’t afford the cost of visiting their doctor.
“The type of business we did see a lot of, such as children’s antibiotics and antibiotics for adults, has really declined. This can be a positive change in some ways because we were probably over using antibiotics, but for certain people who really need this medication but can’t afford to see a doctor let alone buy the tables, this is a very worrying development.”
He expresses concern that some of his regular medical card customers have had their cards withdrawn this year.
“We are seeing more people being refused the medical cards that had them in the past, that’s certainly an impact of the recession. Losing a medical card has a major impact, particularly if someone is on a lot of medication. Suddenly they’re going from paying maybe €10 per month up to €132 a month. That’s a huge jump, and I’ve had some patient confide in me their fears that they won’t be able to afford they medicine.
“Then of course, there are people in the same dire situation who you don’t even get to talk to. They just don’t come in. They’re too embarrassed.”
Kathy Maher, a pharmacist in Duleek, Co Meath, tells Modern Medicine of Ireland that she has also noticed an increasing number of people struggling to afford the medication they need.
“This is actually a huge trend, people are cutting back on their medicines or trying to make them stretch,” she confirms. “I’ve noticed this to be particularly stark for people still awaiting their medical cards. For example, they would come into me with their regular prescription but say they’ll just take the blood pressure tablets and go without the cholesterol tablets until they get their medical card.
“But if there is a long delay in issuing the card, and we’ve seen that it can be a very drawn out process, this can be very dangerous. You can’t have patients not take their medicines so we try to help them. It can get expensive for us, though, when you’re giving out that amount of tablets free of charge, but people just don’t have the money to give.”
Kathy also highlights the upsurge in requests for health advice. “We’re inundated with requests for free advice because people are holding off going to their doctor. I’m not complaining about that, it’s what we’re here for and that is certainly one of our key roles, but it can be difficult sometimes when you tell them that your advice for that particular health query is to see their GP. People are crest fallen, ‘please don’t tell me that,’ they say, because they simply don’t have the money to spend.”
Patients are not the only ones feeling the pain of the economic downturn. Independent pharmacies across the country are suffering too, faced with leaner budgets, streamlined staffs, and more State cuts in the pipeline.
In Ireland, the State pays for approx 80% of all medicines, amounting to an annual cost of almost €2 billion – one of the highest State pharmaceutical bills in Europe. The pharmacy sector has already contributed nearly €400 million in savings to the Exchequer through reductions in payments introduced under the Financial Emergency Measures in the Public Interest (FEMPI) Act in 2009.
With the new Health (Pricing and Supply of Medical Goods) Bill likely to pass into law by the year’s end – heralding a new system of generic substitution and reference pricing - the Department of Health hopes to shave €50 million off the annual drugs bill. A further cut in the cost of medicines will be realised in a new agreement between the Irish Pharmaceutical Healthcare Association (IPHA) and the Department of Health, which is at an advanced stage.
Pharmacists are finding themselves caught between the proverbial rock and hard place as they welcome savings to patients and the exchequer while also lamenting the damaging impact cuts are having on profitability, stability and viability of the community pharmacy sector.
“It’s very difficult, both as a small business owner who has already been forced to close one business, and as a pharmacist who wants to help her patients to the best of her ability. You want to do the very best for your patients, but you’re feeling the pinch every which way,” admits Kathy, who is Vice-President of the IPU.
In February this year, Kathy had to shut the doors of her pharmacy in the small village of Donore, Co Meath, after a little over three and a half years in business.
“My husband, who is also a pharmacist, and I bought the pharmacy in Duleek six years ago, and we opened a pharmacy in July 2008 in Donore village, but after so many cuts to our income, and having curtailed services to the point that I worked there without a wage, we just couldn’t maintain the business. That means an entire community now has no pharmacy service because it was the only pharmacy in that area.”
Her IPU colleague Rory O’Donnell has had a similar unfortunate experience. In 2006, he purchased a pharmacy in Letterkenny, Co Donegal, but was forced to close this year.
“During the past couple of years business declined drastically at a rate of knots, despite every effort to keep it on the road. It was difficult, particularly for my patients and my staff,” he recalls.
His pharmacy in Gweedore, Co Donegal is largely a GMS business, in that 90% of income is from medical card patients. “The direct cuts imposed since 2009, which have impacted the State schemes, have hit us very hard here,” Rory explains.
“The biggest threat to Irish pharmacy in terms of finance is the ongoing cuts that have devastated pharmacy, there’s no question about it. Pharmacy has survived but many are hanging on by their fingernails.
“Front-of-counter sales have also declined severely, and recent CSO figures would back this up; front of counter pharmacy sales have fallen probably more rapidly than most of the retail sector. That side of the business is evaporating no questions about it.”
Kathy agrees that sales in OTC medicines, cosmetics, toiletries and other luxury goods have dropped drastically.
“When we bought the business, the split might have been 60% medical card and 40% front-of-shop. Our latest reconciliation a few months ago showed that income from front-of-shop is now only 9%.”
A recent IPU Business Trends Survey revealed that six out of 10 pharmacy owners say the business environment is getting worse, and almost a third of pharmacists report that costs have increased, due to hikes in energy costs, waste charges, commercial rates and rents.
As President of the IPU, Rory says the challenge now is to ensure that community pharmacy is enabled to diversify and deliver new services, which requires a more strategic approach to be agreed for the delivery of community based healthcare.
“We need to extend the roles of pharmacists as part of the primary care network, introducing initiatives such as medicines use reviews, repeat dispensing, and switching more medicines from prescription only to pharmacy only, so that we can treat our patients in a more timely manner. These initiatives will benefit pharmacy going forward,” he stresses.
It appears the notion of pharmacy as a recession-proof profession has gone the way of bank job security and property portfolios. As John points out, when the country isn’t doing well, pharmacy will feel the impact.
“We are very heavily dependent on the Government who is our biggest customer, and when your biggest customer is the Government, how could you be recession proof?”

Pharmacists can help with depression

The Irish have a hard time opening up when they’re feeling down. Depression is still a difficult subject for people to talk about in this country, with one in five (20%) admitting in a national survey that they are embarrassed to discuss depression with others, including healthcare professionals.
Depression is a common and serious illness but fortunately the majority of sufferers, even those with the most severe depression, can get better with treatment. Medications, psychotherapies, lifestyle modifications and other methods can effectively treat people with depression. However, far too many people with a depressive illness will never ask for help.
A recent nationwide campaign is encouraging people who are struggling with depression to seek advice and support from their local pharmacists. The Lean on Me Pharmacy initiative - a follow on from the Lean On Me depression awareness campaign - aims to reinforce the pharmacists as an important point of contact and support for people with depression.
Research has confirmed that community pharmacists can play an integral and multifarious role in tackling depression, such as identifying those suffering from a depressive illness, enhancing management strategies by providing patient education, assisting in monitoring treatment effectiveness, improving medication adherence and identifying and managing side effects.
While most people are very comfortable talking to pharmacists about physical conditions like colds, headaches and minor injuries, they may not necessarily associate pharmacists as source of support for depression. Only 35% of people surveyed in Ireland are aware that a pharmacist is able to advise about depression.
Lean on Me Pharmacy Campaign
The new Lean on Me Pharmacy campaign is the first step in strengthening this association and making the Irish public aware of the availability and accessibility of pharmacists as health experts who can offer a helping hand to people with depression.
“Community pharmacists are healthcare professionals who are just as qualified to support people living with depression as they are to advise on other chronic physical ailments like diabetes and high blood pressure. While research shows a significant number of people do feel they can approach their pharmacist about depression, we want to reach out to everyone who may have depression, which is why the Irish Pharmacy Union (IPU) has joined the Lean on Me campaign,” said Rory O’Donnell, IPU President, at the launch of the campaign in May.
About 500 pharmacists in Ireland participated in certified training courses around the country, under the Lean on Me Pharmacy initiative. These refresher courses offered pharmacists an overview of medical depression and the benefits of optimising anti-depressant therapy, as well as new engagement tools and how they can offer support for customers living with depression.
“Many people still have difficulty talking about their depression,” said Ultan Molloy, proprietor pharmacist at HealthWest Community Pharmacy in Ballindine, Co Mayo, who took part in the training course. “Figures from a national survey published at the time of the Lean on Me Pharmacy launch were quite astounding to me. Four in ten people said they would not want to know if a friend or loved one was suffering from depression, and a similar number said they would be embarrassed to talk about their depression with others, including with a health professional.
“That’s very unfortunate. I hope community pharmacists can help make a difference and change that situation,” he told Modern Medicine of Ireland.
Ultan’s pharmacy in Mayo has earned a widespread reputation for it’s friendly approach to customer service and last year was a finalist in the national JCI friendly business awards.
“We’re a community pharmacy in a rural area so our customer care is as much about having the chat as it is about dispensing medicines. Given the stigma that still exists around mental health, if we want people to open up about their depression, trust is key. They need to trust the person they’re talking to and they need to see that you are a competent professional, someone who can in fact guide them,” he pointed out.
Ultan Molloy and staff at HealthWest Community Pharmacy
“I believe pharmacists in general have very engaging and positive relationships with their patrons. We’re not just a drug delivery system. We’re health professionals and we’re available for long hours at the counter or in our consultation room to have a chat to someone if they need that extra time.
“The more we help people to trust and open up to us, the more we can engage them and ensure that they are getting the most appropriate treatment for their symptoms. It may start off with a bit of a chat then gradually they can open up and tell us what is going on with them. When they are in that zone of feeling comfortable and feeling cared for, they are more likely to confide in you.”
International primary care surveys show that only 50% of people with depression seek help: of those who do, only half had depression diagnosed and adequately treated. By expanding community pharmacist involvement in the identification of patients with depression and in their care, health authorities hope to maximise the impact health professionals make on the lives of those who suffer from the disease.
For patients with a diagnosis of depression, community pharmacists can help improve outcomes at every step of the patients' treatment by provide patients with realistic expectations, recognising drug interactions, managing side effects, and recommend alternate treatment options.
The importance of not stopping medication too soon is a message that can also be reinforced by a community pharmacist. Non-compliance with antidepressant medication is a serious issue. Patients with depression are three times more likely not to take their medications as compared to the general population.
“The pharmacist is a critical point of contact really. With the majority of anti depressants that are most popularly prescribed, the patient will only see an initial effect after two to three weeks, and for that interim period the patient may be a little up and down. So it’s important that they have positive expectations and a belief in the benefits and efficacy of the treatment, and that they don’t abandon their medication before it has been given the opportunity to work,” advised Ultan.
The Lean on Me Pharmacy survey confirmed that the majority (65%) of people would accept advice from a pharmacist if advised to continue on antidepressants, which underscores the relationship of trust that already exists between the pharmacist and patient.
Community pharmacists are also an important point of information and practical advice, Ultan emphasised. “We can provide educational material around the nature of their illness and encourage people to talk things over with their friends or a self help group. Some dietary supplements have also been shown to have benefit, such as Omega-3 and vitamin B complex, which can be good in terms of reducing stress and has been shown to improve mental functioning.
“A healthy balanced diet and sufficient exercise is also vital; addressing some relatively minor lifestyle changes an have a significant impact on how one functions day to day”
“In my mind, drug therapy is great and it has a very important role but whatever the issue was at the start of drug therapy, if someone wants to address their mental health issues then they will need to strive to address any underlying issues when they are feeling up to it,” Ultan suggested.  “One can externalise and say ‘the medicine will fix me’, but I would be encouraging people to look at how they can address the problem as themselves as much possible through lifestyle modification and counselling - basically empowering them to put strategies in place and giving them the opportunity, while they’re on the drug therapy, to tackle the root causes of their depression.  There are of course unfortunately some cases where patients will need to stay on medication over a long term, and we’re here of course to make ourselves available and support them. Patients can touch base with us and with their GP periodically until we get to an appropriate effective dose.”
Community pharmacists also play an important role in recognising cases of undiagnosed depression. Ultan remarked that, in his experience, it is quite common for a person to not even realise that he or she is suffering from depression.
“It has happened countless times; someone will come in looking for something to help them with a minor complaint, such as sleeplessness or they have stomach problems. They may not be aware that the cause is actually that they may be depressed.
“With experience and engagement you can prompt people to bring the real issue into their consciousness, which can help in terms of acknowledging that there is a problem. Simple things, such as asking ‘do you feel like you’re under pressure at the moment?’ or ‘it sounds to me like you’re not performing the best’.
“For example, someone comes in with sleeping problems and during our chat I might tease out why they’re not sleeping and maybe identify other symptoms of depression.
We can then talk these things through with our patients and refer them on to their GP for diagnosis and prescribed treatment where appropriate
For some people, admitting that they’re feeling depressed can be very difficult, people may see it as a weakness or something they have done wrong or done to themselves. Whereas, the message we need to be getting across is if you have a chest infection you get an antibiotic, if your mental health is off kilter then you get that sorted out as well, it’s just as important, if not more important,” he stressed.
“The main message for pharmacists is that we need to get out from behind the counter and start engaging with patients. That’s where it is at, in my mind. We’re not a drug delivery service, we’re healthcare professionals. It’s up to members of the professional to start connecting with customers in a real way, get to know them and see how you can help them, and give them that added value.”