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Dispensing with dispensing docs?

Dispensing doctors are GPs who routinely issue medicines to patients, where they generally would be unable to access vital medications due to their location, age and health status.

In 2016 there were more than 100 dispensing GPs in Ireland. Today, there are just 65.

This figure looks set to drop further following a HSE attempt to terminate 13 dispensing doctors’ contracts in November 2017.

The GPs in question were issued a two-week termination notice, but many have appealed the action and are currently awaiting a final decision on their fate.

Furthermore, the HSE has advised it is planning to examine the contracts of more dispensing GPs in 2018, an action that could lead to another reduction in numbers.

So, why is the HSE terminating dispensing doctors’ contracts? And could the move result in the further loss of rural GPs and practices and adverse outcomes for patients?

History – a vital service

Dispensing GPs generally practice in remote areas, far from pharmacies and towns and are paid a dispensing fee by the HSE under an agreed contract.

They have been an important and integral part of community healthcare in Ireland for decades. Their existence, particularly in rural areas, has served communities well, providing critical healthcare to remote, elderly and vulnerable patients.

The GMS contract of 1972 sets out the rules regarding dispensing GPs. They include the proviso that when a pharmacist opens a pharmacy within three miles of a dispensing GP “his eligible patients will cease to have a choice between him and the pharmacist for dispensing purposes”.

This is one of the reasons why the number of dispensing GPs has decreased in recent times, as more pharmacies open up in rural areas.

But the contract contains an exception to this rule.

“Where a medical practitioner lives within three miles of a pharmacist but where… it would be a hardship on certain individual patients because of disability to obtain their prescriptions from the pharmacist, the medical practitioner may, in such instances, be required to dispense for the patients,” the contract states.

A significant change to the contract as it relates to dispensing GPs occurred in 1999. Following agreement with the IMO on new procedures and arrangements relating to dispensing, a circular was issued by the Department of Health outlining the changes.

The changes were sought for many reasons, including the need to bring about “better and more rigorous accountability”, according to the circular issued to dispensing GPs at the time.

The amendments also aimed “to ensure the highest criteria and standards of performance by dispensing doctors” and “to reflect changing demographic patterns and needs”.

The changes led to the computerisation of dispensing arrangements and set out a minimum 70 per cent dispensing/prescribing ratio requirement.

The circular states that “a dispensing doctor operating under the new arrangements and procedures who fails to achieve the minimum 70 per cent dispensing/prescribing level in three successive years will be removed from the dispensing scheme and decisions to remove based on this objective measure of performance will be final and conclusive”.

According to data from the HSE Primary Care Reimbursement Service (PCRS), 67 dispensing doctors dispensed medication to over 24,000 patients in September 2017. But it is understood that currently there are 65 dispensing doctors nationally.

Dispensing doctors are paid €3 per patient per month and their total payments amount to around €1.1 million annually. Payments are worth about €10,000 per annum to a GP.

HSE termination notice

In November the HSE wrote to 13 dispensing doctors to inform them they had been issued with a two-week contract termination notice for failure to achieve the minimum 70 per cent dispensing level in three successive years.

The move was greeted by affected GPs with shock and dismay. At least one GP has warned that the termination could result in the closure of their practice, according to the IMO, which has been contacted by many of the GPs in question for assistance in appealing the decision.

Despite the reasons given by the HSE for the termination, it is not known why it is seeking to terminate dispensing contracts, especially when dispensing GPs provide a vital service in rural areas where it is increasingly difficult to attract GPs to work.

A HSE review of GP dispensing practices was due to be carried out a few years ago and a report undertaken, but nothing has been published by the HSE to date and it failed to respond to queries regarding the review.

Outcry

The IMO, NAGP, and Rural, Island and Dispensing Doctors of Ireland group have all condemned the HSE’s attempts to terminate the contracts of a number of dispensing GPs.

Mayo GP Dr Jerry Cowley, Chairperson of the Rural, Island and Dispensing Doctors of Ireland, described it as a “bolt out of the blue” and said it could well spell the end of those practices.     

“Dispensing doctors are providing an invaluable service to the ill  and most vulnerable and older of our population, particularly in remote and isolated areas of Ireland. These are areas where it is not viable for a community pharmacy to set up and where the local GP is providing essential medicines instead,” Dr Cowley told the Medical Independent (MI).

“We wish to protest the unfairness of the action and the short notice period given. Attempts by doctors to achieve 70 per cent dispensing to their eligible dispensing patients is being frustrated and severely curtailed by the HSE.”

Dr Cowley argued that it is impossible for most dispensing GPs to achieve dispensing of 70 per cent of their panel for a number of reasons.

These include the fact that dispensing doctors are not allowed order or dispense high-tech medicines to eligible patients and they are also not permitted to order or dispense novel oral anticoagulants (NOACs).

“Virtually all warfarin patients are now on NOACs and the number of patients on these drugs has grown astronomically,” Dr Cowley explained.

A huge increase in the number of eligible patients requiring medicines dispensed in phased packs also means that dispensing GPs have to pass this work on to the nearest pharmacist as rural doctors are not yet resourced to provide this service, Dr Cowley added, noting that dispensing GPs would willingly provide this service if resourced to do so.

Finally, he claimed that “stock orders submitted by dispensing doctors are consistently interfered with by HSE community pharmacists, with quantities frequently marked down by half at least, thus further frustrating the ability of the dispensing doctor to dispense to 70 per cent of their eligible patients”.

“This is yet another major blow to rural Ireland where dispensing doctors are part of the essential infrastructure. It further compounds the vicious circle of ongoing erosion of essential services,” Dr Cowley remarked.

Reality

Dr Kevin Quinn, a GP at Arranmore Health Centre, an island off the coast of Donegal, is a dispensing GP.

He has yet to hear from the HSE with regards to the continuation of his dispensing contract, but does not expect to as he dispenses at a much greater level than the required 70 per cent.

He also highlighted that dispensing GPs are not allowed to dispense high-tech medicines to patients.

“Because the high-tech medicines, which contribute a much greater cost, are dispensed by the pharmacy but picked up in the practice, they [HSE] reduce the figure which is based on ingredient cost (cost to HSE),” Dr Quinn explained.

He also noted the difference in payments in terms of how the HSE treats pharmacists in comparison to GPs who dispense.

“Doctors get an annual fee for dispensing. It’s not a lot and provides a great service in isolated areas,” Dr Quinn told MI.

“Pharmacists get a dispensing fee per item. For example, for phased dispensing, which albeit involves a little more work than regular; if they phase dispense four to five items they would get €70 per month or €840 per annum for one patient.

“I think it is obvious that the powers that be have absolutely no interest in rural dispensing or for that matter rural doctors and regard them as an anachronism.

“The key issues for rural health workers are recruitment, retention and remuneration. Alas policies do not seem designed to address any of the issues.”

Dr Kieran Murphy, a GP in Athea, Co Limerick, is another dispensing GP. Around three years ago the PCRS wrote to him issuing a termination notice.

“We contested it,” Dr Murphy confirmed to MI.

“There was a lot of petitions and publicity about it at the time and we went through the appeals process with the IMO and took their advice.

“We service an outlying centre and we told the PCRS we could not afford to continue providing a service there without dispensing.”

At the time the PCRS noted the 70 per cent rule in their justification for the move. It was also alleged that a significant number of medical cardholders in Carrigkerry (where the outlying centre is located) were also attending GPs in Newcastle West.

But with support from the local primary care/GP unit, the IMO and others, the termination notice was never executed.

Dr Murphy currently has a GMS list of around 1,100-1,200 patients and about a fifth of that panel is dispensing.

Following the latest move by the PCRS, Dr Murphy believes it wants to get rid of dispensing GPs.

“The HSE locally and the local GP unit are very supportive of GPs and their patients. But the PCRS…always go on solo runs and take no notice of anyone. They seem to have very little comprehension of the reality of how care is delivered. They are money men looking at costs and are not looking at the hardships they are inflicting on patients,” Dr Murphy said.

“Dispensing is a vital service for isolated rural areas. Yes, a lot of young people have transport but a lot of older people do not and there are many areas that are at least 10 or 12 miles from a pharmacy.”

Until a few months ago Dr Murphy was dispensing NOAC drugs, but he has been informed by the PCRS that he is no longer permitted to do so. The PCRS did not give a reason for the change, Dr Murphy said.

“Do they ever give a reason?” he added.

Appeals

All the dispensing doctors contacted by the HSE in November were dispensing less than 10 per cent by the PCRS calculation, it is understood.

The 1999 circular states that dispensing doctors will be advised on an ongoing basis of their performance and in any year that a dispensing doctor fails to meet the 70 per cent minimum level they will be formally advised of that fact and the implications of failing to reach the target in future years.

Yet MI understands that not all doctors were informed of their performance annually.

Mr Val Moran, IMO Director of Industrial Relations, General Practice, Public and Community Health, said that the IMO submitted an appeal to the HSE on behalf of five dispensing doctors that made contact with them.

The IMO has agreed an appeals mechanism with the HSE for those dispensing GPs who wish to appeal the decision.

He said the HSE has responded to say that they are considering the appeals. The situation will remain unchanged until such time as a decision has been made on the appeals. It is expected a decision will be made at the end of January.

“The IMO is opposed to any plans to reduce the number of dispensing doctors,” Mr Moran stated.

“These doctors provide a vital service to vulnerable, isolated patients. While the 70 per cent threshold may not be met in many cases, this is increasingly difficult with the advent of blister packing and high-tech drugs, which can only be done through the pharmacy. This has to be seen as a support to rural GPs who otherwise would not be able to provide a service to their patients.

“In many cases these are small lists in rural areas, which are not viable without rural practice allowances and dispensing fees. If dispensing fees are removed these lists will not be filled on a permanent basis and lead to the loss of GPs in remote rural areas.

“The total spend on dispensing fees per annum is close to €1 million, which is 0.0018 per cent of the total PCRS GP budget. If the removal of dispensing fees leads to a doctor leaving the GMS and not being replaced it will prove to be short-sighted in the extreme and a case of penny wise, pound foolish,” he told MI.

Due to concern surrounding HSE plans to examine the contracts of more dispensing GPs this year, the HSE has agreed to engage further with the IMO before issuing any more correspondence.

NAGP

NAGP President Dr Emmet Kerin described the move by the HSE to terminate dispensing doctors’ contracts as “crazy” considering they are remote GP practices with no access to pharmacies locally.

“It really doesn’t make sense to pull a service like that,” Dr Kerin noted, describing the 70 per cent rule quoted by the HSE as justification for the move as “arbitrary”.

He said the NAGP has been in touch with affected dispensing doctors and with the HSE on the issue.

In 2016, the NAGP revealed plans to carry out a study into the feasibility of members dispensing commonly-used medicines, such as antibiotics and blood pressure and cholesterol drugs, to patients, and potentially making OTC medicinal products available in their surgeries too.

The plan was met with resistance from the Irish Pharmacy Union (IPU) at the time. It has since been put “on ice”, Dr Kerin said.

While dispensing GPs operate under an agreed set of conditions for dispensing under the GMS contract, there is no prohibition on GPs dispensing medications directly to patients once they adhere to the relevant standards and guidelines.

A number of GPs working in out-of-hour co-ops regularly dispense medication directly to patients if there are no pharmacies open during the night.

Yet it is not envisaged that GPs will begin dispensing medications to patients en masse in Ireland, considering the availability of pharmacies in urban areas.

WHO

Furthermore, literature from the World Health Organisation (WHO) notes that it is generally accepted that “dispensing is an area of competence of pharmacy staff rather than the medical profession”.

“In many countries the functions of prescribing and dispensing are kept separate, principally to avoid a conflict of interest on the part of the prescriber, who could profit from both prescribing and selling medicines. This separation also optimises rationality of therapy by having pharmacy staff or pharmacists, who are specialists in this area, review prescriptions and ensure good practices in dispensing.”

Yet, it is evident that in remote, rural areas in Ireland there is a great need for dispensing GPs, particularly considering the recruitment and retention difficulties general practice is currently experiencing.

MI on several occasions sought a response from the HSE to questions concerning the termination of dispensing GP contracts. No response had been received at the time of going to press.

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