Any savvy political adviser who wants to come up with a solution to the State’s soaring bill for drugs and many unnecessary hospital admissions should pick up the phone and book a Galway city tour with pharmacist Frank McAnena.
McAnena's circuit is a thrice-weekly one, where he packs up his car with medicines and visits people of all ages and backgrounds across all parts of the city, from Oranmore on the south-east to Knocknacarra and Rahoon in the west.
His doorstep calls are not just deliveries of blister packs, however. During that quick chat, he can gauge how a person is, whether they are taking their medication, and how frequently that might be. As Galway West TD Hildegarde Naughton observed when shadowing him, one cannot put a figure on the benefits of that brief human contact.
Ireland is one of the top spenders on drugs in Europe, equating to about 10 per cent of the health budget. A review for the Department of Public Expenditure and Reform published in May 2017, recorded total public expenditure on pharmaceuticals at €2 billion in 2016. Some 21 per cent of this related to drugs dispensed in acute hospitals, while 76 per cent was through primary care.
However, recent research in Britain found misuse of medicines has been costing the health service £500 million a year. Similar research in the US has estimated non-compliance costing billions of dollars annually, due to patients either forgetting to take prescribed medication or improperly administering same. Those costs relate not just to the wasted drugs, but the associated development of complications, more frequent hospitalisation, serious illness and death.
Eight years ago, when McAnena came up with the idea of making home calls, he knew of one diabetic patient who had 14 unopened boxes of insulin worth €700 in his fridge, and a psychiatric patient with €900 worth of medication in a drawer.
He had encountered situations where children as young as 11 years’ old were trying to handle pills for chronically-ill parents. Another woman with literacy issues was being deprived of her medication by relatives.
Early detection
While blister packs used in pharmacies resolved some issues for those with poor memory, and home care visits to the elderly could also assist, McAnena realised that weekly deliveries of medication would allow for early detection of issues. "I remember meeting psychiatrist Dr Ivor Browne on a visit to Grangegorman in Dublin many years ago, and the amount of medication for psychiatry would fit in a small sweet shop. Now medication is very, very complex, and if you are handing over medication worth €5,000 a year to a patient with no supervision, does that make sense?"
One of McAnena’s clients , who lives 10km outside Galway and suffers from depression since she lost her daughter, takes about 30 tablets a day, up to 10 of which are at one time. “These were all prescribed while I was in hospital,” the client, who would prefer not to be named, explained to this newspaper. “I have had two attempted suicides, one of which was when Frank was at the door with my meds.
“He knew there was something wrong, and wouldn’t leave and called the psychiatrist. A nurse came out and brought me to hospital, so he actually saved my life. Previously, I would be admitted for forgetting to take medication or not taking the right dose, but I have got into such a routine with Frank that it means I have had only one admission in the last seven years and that was only because I was physically sick,” she said.
“ He is just amazing in the work he does, and he never looks at his watch when talking to you – he gives you as much time as you want, or as little as you need,” she added.
About the same time as McAnena was undertaking his first visits by motorbike – earning him a nickname, the "Harley Davidson man" – a similar model was established in Devon and Cornwall. It involves an integrated community health and social-care service for about 145,000 people.
The Exeter Cluster Pharmacy in Devon undertakes clinical medication reviews for frail older people at home, assessing the risk of medicine-related harm to reduce risks and potentially prevent hospital admissions or reduce re-admission . A subsequent review found it saved about £100,000 annually.
Five years ago, the Royal Pharmaceutical Society in Britain published a report which also proposed that pharmacists could play a vital role in community medicine. Entitled Now or Never: Shaping Pharmacy for the Future, the 2013 report recorded cases such as that in Croydon, where the local authority had commissioned community pharmacists to undertake medicine-use reviews, while several London and east Lancashire hospitals also employed pharmacists to manage complex patients in the community.
‘Missing link’
It described such pharmacists as the “missing link” in ensuring patients were safely discharged from hospital, avoiding unnecessary readmissions.
Forgetfulness, isolation, fear of side-effects, and multiple drug regimes are among the most common causes for non-compliance, McAnena says. Cost is also a factor. A GP may not realise it is an issue, and may increase a dosage – increasing both the risk of more side-effects, and even greater levels of non-compliance, he says.
So why has McAnena's model not been adopted more widely here? It is not for the want of trying on his part, and that of several researchers who have worked with him. He has met several health ministers, including current Minister Simon Harris last year .
The Department of Health says while it has a record of that meeting in Galway, it has no record of any submission. McAnena says a written brief was handed to Harris at the time.
Hildegarde Naughton believes McAnena’s model could have applications for the Government’s new health strategy, Sláintecare, but also believes it is up to pharmaceutical representative organisations to push for it.
The Irish Pharmacy Union (IPU) says it "fully supports any measures that would help patients to take their medicines correctly and to get the best outcomes possible".
“Pharmacists, as the most accessible healthcare professionals, want to be allowed to practise to their full scope to support patients and the health system,” it says.
“The IPU has repeatedly and consistently made constructive evidence-based proposals to the Minister for Health in this regard, using successful services in Ireland and overseas as examples.
"Unfortunately, neither the Department of Health nor the Health Service Executive has yet engaged with us on these proposals."
Frank McAnena says he hopes Harris will commission a pilot study, at least, and that he might see some results before he retires. “Providing the right sort of support for complex medications could make such a difference to people’s quality of life . . . I think that is something that Simon Harris understands.”
