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?”