Primary healthcare encompasses health and social services in which care is provided in the community rather than in hospitals or other institutions. The recently-leaked document, Recommendations for Primary Care, suggests that we can all anticipate significant changes in the area over the years ahead.
The recent report by Dr Muiris Houston in this newspaper indicates that consideration is being given to a team-based approach to the delivery of primary care services and the provision of an 1850 number to provide easy access to a "one-stop shop" healthcare system.
In its submission to the National Health Strategy Forum, the Irish Pharmaceutical Union (IPU), which represents the interests of community pharmacists, advocated greater collaboration and co-operation between healthcare professionals at a local level because we believe this offers the potential to greatly strengthen the effectiveness of services from a patient's perspective.
We welcome, therefore, any proposals for greater collaboration with other healthcare professionals and the users of primary healthcare services. However, we would draw a distinction between collaboration and a "one-stop shop" approach.
We would not favour the latter because we believe it would mean unnecessary State involvement in service delivery and would have a negative impact on the commitment of healthcare professionals, including pharmacists, to the communities within which they operate and, ultimately, on the services themselves, both in terms of choice and quality.
Nevertheless, social, economic and demographic change requires a continuing reassessment of health services. For example, one of the positive outcomes from increased prosperity is the fact that people live longer. Older people will continue to account for an ever-increasing percentage of our population. They wish to live normal independent lives in the communities where they feel most at ease, supported by locally-based health and social services.
In this context, the rational distribution of such services has to remain a firm public policy objective. The availability and correct uses of modern medicines are essential for an independent life.
However, many older people and others who are unable to fend for themselves are frequently on long-term and complex drug treatment for multiple disease states. Managing multiple medicines in such circumstances may be confusing, and a high proportion of pharmacists' time is absorbed in counselling such patients on the correct use of their medicines.
However, after-supply compliance with multiple treatments is not monitored in any structured manner and, consequently, many patients do not get the optimum benefit from their medication.
It is noteworthy that the National Service Framework for Older People, introduced by the British government in March, provides a blueprint for medicines management and recognises the role of the community pharmacist is ensuring that older people get the maximum benefit from their medication.
In this context, readers will be aware that there has been much comment in the media recently about the impact of the 1996 community pharmacy regulations on the distribution of pharmacy services. Very little attention, however, has been paid to the contract entered into by pharmacists with health boards as a consequence of the regulations.
Clause 9 of the contract introduced a major advance in that it gave recognition to community pharmacists' expertise in medicines and specified the duties of pharmacists. These include reviewing the medicine therapy of the patient, therapeutic duplication, drug-drug interactions, incorrect drug dosage or duration of treatment, drug allergy interactions and clinical abuse or misuse.
Pharmacists have also taken on significant roles in the areas of long-term illnesses and high-tech medicines and in administering the community-based methadone programme. These activities offer the potential to reduce medicine and drug-related morbidity, with consequent savings to the State.
The IPU views the development of Clause 9 as the beginning of a process which will lead to the State resourcing and development of a pharmaceutical care service.
The concept of medicines management or pharmaceutical care originated in the US and provides for the monitoring of patient response to prescribed medication. Currently, there is a gap in patient care in that, once a patient has obtained prescribed medicine from a pharmacy, there is no active assessment procedure to see if the medication is appropriate, is being correctly used or is producing the desired effect.
Under a pharmaceutical care service, the pharmacy will remain in communication with the patient to establish if he or she is experiencing any problems with the medication and, in consultation with the local doctor or other local healthcare professional, will advise them on what action should be taken. This follow-up service is repeated regularly.
Such a system provides the optimum benefit for the patient and ensures that prescribed medication is used in the most effective way. This has been proved to make a significant contribution to reducing costs in other parts of the health service through lower admissions to hospital or other forms of residential care.
The provision of a pharmaceutical care service will require resources. The IPU has recommended that the State should fund a number of pilot programmes to establish the effectiveness of such an approach. In addition, pharmacists could take on an expanded role in health promotion and in other areas. This is the direction in which the IPU would like to see pharmacy going in the future in the context of an overall health strategy.
Resources spent in the primary care area will reap rich dividends for the State and society. In this regard, it is equally important that resources are not distributed too widely but are targeted at those who have not experienced the impact of the Celtic Tiger. These include many elderly people living on small pensions or in isolated rural communities, one-parent families, Travellers, the long-term unemployed, those with long-term psychiatric problems, asylumseekers and the homeless.
Apart from the normal services, it can sometimes be overlooked that some of these vulnerable groups often require advice and assistance on improving their living conditions and nutrition. The proposal to provide an 1850 contact line will provide a listening ear, comfort for many and reassurance for others who require services, particularly outside normal hours.
However, the telephone line is not an end in itself and, while it could become a stepping stone to a particular community-based service, it should never become a substitute for personal interaction with a healthcare professional.
If the optimum benefit is to be derived from primary care services, it is important that those providing the services co-operate and work as a team. Where local initiatives to improve doctor-pharmacist relations have been established, they have been shown to be of benefit to both professions.
In this context, the IPU believes that it is time to review the role of the health board primary care units established in 1993. While the basic model is good, they have developed along different lines in different health board areas.
To date, their focus has been mainly on general practitioner services and related matters. We believe that these units can only achieve their full potential with more interaction and co-operation between healthcare professionals and with involvement and feedback from the users of the services. They should not be allowed to become another talking shop but should have a clear focus on patients' needs.
The scope of the primary care units should also be broadened to include other primary healthcare professionals, such as practice nurses, dentists and public health nurses.
The remit of the units should encompass the planning of health promotion projects in conjunction with educational bodies such as the Irish College of General Practitioners, the Irish College of Continuing Pharmaceutical Education and the Department of Health and Children.
Our experience of such approaches is that without a clear strategy and involvement at a national level, the units will not be as effective as they could be.
To summarise:
The first and only contact for many patients with a healthcare professional will be with either a general practitioner or a community pharmacist, and their participation will be critical to the success of any new approach to the primary care area.
Primary care is the most accessible and frequently used part of the health service. For example, it is estimated that over 40 million visits are made to pharmacies each year, of which at least 10 per cent results in a request for advice on an ailment or medicine issue.
Effective intervention at primary-care level eases pressure on other more complex and expensive parts of the service, such as hospital care and long-term residential facilities.
Investment in this area can significantly improve the quality of life for individuals as well as reducing morbidity and improving life expectancy, thus paying a rich dividend in reducing costs elsewhere in the health services.
Timely and effective interventions minimise costs on the wider economy arising from poor performance or absenteeism due to illnesses.
The percentage of our population which falls into the elderly category is increasing, and most of these people want to continue to live independent lives in their own communities. However, they will need the support of a range of health and social-service providers.
Pharmacists play an important role in primary care, and we believe there is considerable scope to develop this role in the interests of the consumers of health services.
It is important that there is cooperation and understanding between the State and the various healthcare professionals, among the professionals themselves and that the voice of consumers is brought to bear on such services.
Mechanisms must be put in place at national level to provide direction and co-ordinate the activities of community-based primary healthcare teams. It is equally important that there be means of recognising and replicating good practice, piloting new and more innovative approaches to healthcare delivery and providing the necessary feedback to inform ongoing policy changes or direction.
In conclusion, therefore, the IPU does not favour a "one-stop shop" approach if that is what is being proposed. We accept, however, the need for a more professional and seamless community-based service which recognises the diverse needs of constituent groups within our society. This should be a key objective of the next national health strategy.