Can pharmacists help alleviate overcrowded emergency departments and busy GP surgeries?

As HSE managers scramble to find solutions to record levels of overcrowding in hospital emergency departments and GPs face busy clinics, the role of pharmacists in helping to deal with high numbers of patients sick with viral illnesses has received scant attention.

Dermot Twomey, the president of the Irish Pharmacy Union, says that pharmacies could provide solutions to the current healthcare crisis. “Ireland’s 1,900 pharmacies are located in practically every community. They are easily accessible and should be among the first line of defence for our health system,” says Twomey who owns a busy pharmacy in Cloyne, Co Cork.

Dr Chris Luke, former consultant in emergency medicine at Cork University Hospital, also sees a role for pharmacists in this healthcare emergency. He believes pharmacists should be enabled to provide much more primary medical care. “Let them prescribe or offer alternatives to a doctor’s prescription where there are shortages of a medication,” he wrote in a recent column in the Irish Examiner. And recent research at University College Dublin highlighted how many community pharmacists feel their competences and skills are under-recognised and under-utilised.

Currently, pharmacists can offer advice on over-the-counter medicines and dispense GP and hospital prescriptions, but they can’t prescribe medicines independently. They can only give alternative medications to patients if there is a shortage of the one prescribed or a patient is happy to take a cheaper generic medicine of the same formulation. During the Covid-19 pandemic, pharmacists were given extra temporary powers to provide repeat prescriptions and emergencies medicines for longer periods of time which is still in force. Many pharmacists now offer flu and Covid vaccination, blood pressure monitoring and emergency contraceptive consultations.

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[ Irish pharmacies could offer so much more for patients, but need Government support ]

Twomey says for pharmacists to be able to play a greater role in alleviating the workload of GPs – and also emergency departments – a minor ailment scheme would have to be legislated for. “This would allow pharmacists to prescribe medicines to patients on medical cards and be paid for the drugs and the consultation by the State. If pharmacists could manage patients with minor conditions such as indigestion/heartburn, athlete’s foot, coughs and cold, this would take pressure off GPs,” he says.

Currently, medical card patients must go to their doctor for a prescription so that they can get free medicines at their local pharmacy.

Safety nets

Aware of the potential conflict of interest as the seller and prescriber of medicines, Twomey says that protocols could be developed with safety nets so that pharmacists could only sell one or a maximum of two products for specified conditions. “This would ultimately free up GPs so that they could deal with more complex cases and similarly hospitals could in turn deal with cases with further complexity,” says Twomey.

Such an approach would see pharmacists as the first stage in a triage system which would then refer patients to their GP if their condition didn’t improve. The Royal College of General Practitioners and the College of Emergency Medicine in the UK have estimated that one in seven GP consultations and one in 13 emergency department attendances could have been dealt with by a visit to the pharmacy.

Many people already approach their pharmacist first with minor ailments such as skin rashes, coughs and minor injuries. But the attention they receive often depends on whether they have a friendly relationship with their local pharmacist or not. And some people feel pharmacists’ bias towards selling products can sometimes override their desire to give advice which would guide individuals towards self-care options with simpler home remedies.

Twomey says that pharmacists give out a huge amount of advice informally. He suggests that such advice should be formalised into paid-for consultations without always involving the need to sell products. “We could do these consultations to a far higher standard if we had access to the patient’s file,” says Twomey.

[ Hospitals will experience ‘extreme’ pressure for a number of years – HSE ]

Dr Brian Higgins, a GP in Galway city, believes there is a big role for community pharmacists in health education but that if pharmacists are to expand their role in patient care, it should be as a practice pharmacist working as part of the clinical team in a primary care centre or GP practice.

Citing an evening shift he did in an out-of-hours GP clinic recently, he says that about 80 per cent of the patients (13 out of 16) had self-limiting viral illnesses and the other 20 per cent needed treatment and a follow-up plan.

“Health literacy is a really big issue and pharmacists can play a key role in educating patients about the use of over-the-counter medications such as paracetamol, ibuprofen, cough syrups, the importance of rest and when a medical review is needed,” says Higgins. He adds that if patients had better knowledge on managing self-limiting viral infections, this would give GPs more time to see patients who would benefit from medical interventions such as those with ankle strains, pneumonia, severe tonsillitis or eye infections.

Clinical pharmacists

Higgins also commends the HSE’s website, undertheweather.ie which offers straightforward information and advice on managing colds, coughs, sore throats, flu, earaches, diarrhoea and vomiting, rashes, high temperature (fever) in children and adults, dehydration and sinusitis. “I text it to all my patients and ask them to read it and come back to me if they have any questions,” he says.

In the UK, there are a number of clinical pharmacists who work as part of general practice teams. Their roles include medication reviews for patients, helping manage long-term conditions and giving advice to those on multiple medications. They also play a pivotal role in ensuring patient safety in relation to medications.

The Galway Primary Care practice on Tuam Road, Galway, where Higgins works is one of the few practices in Ireland that has a pharmacist as part of the shared care team. “Our pharmacist, Grainne McCormack, is amazing in helping to deliver safe, quality care to our patients. She reviews all the requests for repeat prescriptions and advises patients on whether the repeat is appropriate or if a medical review and other investigations are needed,” explains the doctor.

[ Hospital overcrowding should be treated as a ‘national crisis’, says INMO ]

According to Higgins, having a practice pharmacist not only enhances safe prescribing and follow-up but it reduces the administrative workload of the medical team. “This increases our ability to treat as many sick patients as possible,” he adds.

Dr Brendan O’Shea, GP in Newbridge, Co Kildare, and assistant adjuvant professor in primary care and public health at Trinity College Dublin also sees a value in having pharmacists working in GP practices. However, the HSE currently doesn’t offer any financial support to GP practices with medical card patients who employ a pharmacist as part of their team.

“A lot of community pharmacists already do a huge amount of work supporting people with medications above doling out pills and labelling bottles but most Irish GP practices aren’t big enough to make it commercially viable to have a pharmacist or even a pharmacy technician on their teams " he says.

O’Shea does however believe that at a time when GPs are “overwhelmed and underpowered”, there is a need to look at all evidenced-based solutions. “In other countries, pharmacists do have expanded roles and with our ageing population of frail elderly people, there is a greater need for the expertise of pharmacists to safely manage patients taking a number of different medicines which need to be frequently reviewed.”