Official Report: Minutes of Evidence

Committee for Health, meeting on Thursday, 19 March 2020

Members present for all or part of the proceedings:

Mr Colm Gildernew (Chairperson)
Mrs Pam Cameron (Deputy Chairperson)
Ms Paula Bradshaw
Mr Gerry Carroll
Mr Alan Chambers


Mr Gerard Greene, Community Pharmacy NI
Mr Peter Rice, Community Pharmacy NI

COVID-19: Community Pharmacy NI

The Deputy Chairperson (Mrs Cameron): I welcome Gerard Greene, chief executive of Community Pharmacy NI, and Peter Rice, a community pharmacist from McKenzie Rice pharmacy. We really appreciate that you have been able to come at short notice to brief us at the Committee. We know how important the issue is, so I will not waste your time. I invite you to brief us, and then we will move on to questions. Thank you.

Mr Gerard Greene (Community Pharmacy NI): Thank you very much, Chair and Deputy Chair, for the opportunity to brief you here today. We are in unprecedented times, and we really appreciate being given the opportunity to update you on the issues in Community Pharmacy and how we are responding to the developing crisis.

I will start by giving an overview of Community Pharmacy and where we are in the COVID-19 response. Community pharmacists play a front-line role in dispensing medicines to the public and in giving advice on how to manage those medicines. There are just over 530 community pharmacies in Northern Ireland, which collectively deal with around 123,000 people per day

Since the COVID-19 pandemic was announced, community pharmacists have seen a huge surge in the numbers of people in the order of several thousand per day coming through their doors, and that is happening right across the network. Pharmacists and their teams of staff have been literally working round the clock to manage the numbers, manage the prescriptions, replenish stock, see patients and give advice over the last two weeks. Due to that surge in demand, the network is now implementing a range of special measures to try to ensure that the core service is maintained now and over the next few months to deal with the COVID-19 threat and to ensure that the public continue to get their medicines when they need them.

Along with the Department of Health, the Public Health Agency (PHA), the Health and Social Care Board (HSCB) and other primary care partners, Community Pharmacy will play a key role in the health service, which will have to reduce to core services over the coming months. That is to ensure that the vulnerable, the elderly and those with chronic conditions are prioritised and that medicine supplies to those patient groups and the general public in Northern Ireland are maintained.

Over recent days, people will have seen the new measures that many pharmacies are implementing, which include up to 48 hours turnaround time for prescriptions to be ready once they are received by the pharmacy and new screening and exclusion zones in pharmacies, such as counter-style partitioning to reduce the likelihood of spreading coronavirus. That is critical, because if pharmacy teams go down, the pharmacy will have no option but to close. Pharmacies may restrict access with policies of allowing only three people in at a time or, indeed, having people wait in an exclusion zone at the front door. Many pharmacies are starting to take a one-hour break from dispensing duties in the middle of the day to allow staff to recoup and recover from the pressures, to clean and disinfect the pharmacy and to replenish stock. All those measures are being taken in the interest of the public whom we serve on a daily basis.

As you know, over the last couple of days, we have appealed to the public not to visit a pharmacy if they have COVID-19 symptoms. That is to safeguard the health of the pharmacy team and the pharmacy's customers and patients. Those patients are, naturally, in the at-risk groups by virtue of needing the healthcare that we provide. We are asking the public not to stockpile medicines. We have been told that there will be enough for everyone if there is a responsible approach to ordering prescriptions, but that is being challenged at the minute, and some difficulties are starting to appear. We are asking the public — I think they are starting to listen — to be patient with the staff and the teams. They are doing their best.

The pressures facing community pharmacy teams are immense at this time, as I said. That is recognised by the chief pharmaceutical officer and the Health Minister. Pharmacy teams can cope with the workload, but patients just need to be patient, which the majority are, and we thank the public for their understanding so far. The challenge faced by community pharmacy teams because of COVID-19 has already started, and it will continue. Community pharmacy teams have been facing the challenge over the last two weeks. If you look at Italy, you will see that it is the pharmacies that are staying open. They are the only accessible healthcare providers still going when everywhere else is closed. It is vital that community pharmacy services here are protected and resourced so that we can continue to play our role going forward.

This situation will roll for at least 10 to 16 weeks and beyond. Right now, our pharmacy teams need immediate support from the health service and the politicians here in the Assembly. We have solutions and some immediate asks, but speed, as one of the World Health Organization's (WHO) leading public health doctors said recently, is of the essence. Community pharmacy cannot wait any longer. People are trying to cope with an evolving situation here.

The following are some of the solutions that community pharmacy can offer and that are needed. Pharmacy staff teams want to be in their pharmacies. That is what we do; we look after our public. We need immediate access to COVID-19 testing for staff so that staff with symptoms that resemble COVID-19 but who do not have a positive diagnosis can be diagnosed and returned to work. That is crucial. We are assessing the level of self-isolation among team members, and, as of this morning, there are 90 staff across a number of pharmacies, but not the full network, who are self-isolating. That is 20 pharmacists and 70 support staff. It is critical for our teams that we have access to COVID-19 testing so that if staff are presenting with some symptoms, we can determine if they need to isolate or if they can come back and contribute to team working. At the minute, without the staff, who have been brilliant, the service in many pharmacies will simply not be sustainable. Secondly, we need GPs to work with local pharmacies to reduce the blockages that are currently in the system to pharmacies getting the prescriptions from surgeries and contacting surgery staff. We are working with the GP leadership bodies. They recognise the difficulties, but we need local practices to work with the local pharmacies in the interests of the patients to ensure that the patients can get their medicines in as timely a manner as they can.

Pharmacies also need assistance with the financial aspects. We need certainty immediately that we can continue to pay wholesalers and get the medicines from them. At present, with the surge in the number and volume of prescriptions, the purchasing that is done through pharmacies has rocketed, which is putting a strain on the financial operation of pharmacies. We need protection for the pharmacy remuneration and monthly payments. Community pharmacies are also having to commit significant additional resource to their practices for premises adaptation. Many of you will have seen in recent days the screens etc that pharmacies have had to put in. They are not getting any support to take those measures.

Staff are coming in and making themselves available. Pharmacy teams are having to try to get additional staff members to come in, and staff are working overtime. Staff and pharmacy owners are not asking how they will be sorted out. They are just throwing themselves into the challenge of looking after the public. This is coming out of their own pockets. We need an immediate COVID-19 emergency response payment to deal with those costs. We are dealing with the legacy of a 10-year underinvestment of some £20 million per annum in Community Pharmacy. At the minute, Community Pharmacy and the teams in the pharmacies are stepping up to this COVID-19 challenge. The public can see that, but it is not sustainable without support from government and the health service. An immediate and significant injection of funding is required. It is not negotiable. It is required now so that we can cover the additional costs that the public and you, as politicians, can see the pharmacies committing and so that we can keep going and provide the services to patients that we do.

Looking ahead, the whole management of repeat prescriptions must transfer to community pharmacy. It happens in other countries, including Scotland and the Republic of Ireland. Community pharmacy teams know their patients. We have a relationship with those patients, often going across several generations of families. The skill set is there. We have a situation where the prescriptions that we know that the patient needs are in another facility but nobody can access them. We need community pharmacy to take ownership of that important role. That would work for the patient and for the health service, and it would free up time in GP surgeries. That is a simple solution that can happen relatively quickly, and it needs to be prioritised. As I said, community pharmacy is stepping up. This situation will evolve, and there are challenges still to come. However, the Executive have to support us right now by prioritising access to COVID-19 testing for staff and by giving immediate certainty with additional funding.

Before I finish to take questions, I pay tribute to all the staff in all the pharmacy teams across Northern Ireland. They have stepped up. They are coming into work early in the morning. They are working through the day, late into the night and often into the mornings. They are coming in at the weekend, and, on St Patrick's Day, most pharmacies that were closed had a full quota of staff in dealing with the backlog of work. Pharmacy is stepping up to the challenge. The teams have been exemplary. As a profession, we are doing our bit. It is up to the Department and the Executive to immediately step in and prioritise our asks so that our teams can continue to look after our patients throughout the COVID-19 crisis and, more critically, beyond.

The Deputy Chairperson (Mrs Cameron): Thank you very much, Gerard. I have to say that it is humbling to hear about the work that is going on in the background and the care that your profession has for everybody else. It is really humbling to hear that and to hear about the efforts to protect others. Thank you for that.

I have a couple of questions. It is becoming very apparent that testing is vital and essential. You may not be aware of this, but I have already mentioned a couple of times at this meeting that I spoke to the Minister this morning, and he has assured me that real efforts are being made to ramp up testing. It is vital that healthcare workers and people on the front line must receive that testing, where necessary. It is quite scary that 90 people are already self-isolating.

Mr Greene: That is not the full network. Those are the people who have reported back to us. The issue is that, if they have COVID-19, understandably, they have to self-isolate. If they do not have it at present, they still have to self-isolate, but they could be back in the pharmacy. Given the workload, it is so critical at the minute that pharmacy teams have access to the full complement of staff.

The Deputy Chairperson (Mrs Cameron): Absolutely. While we are not scientists, we can assume that we are at a relatively early stage of the crisis. A lot of those people could come back into the workforce, and we need them back in there.

The other issue is drug supplies, in particular paracetamol. When I spoke to you yesterday, you mentioned that there was an issue with paracetamol in particular. Do you want to go into detail on that?

Mr Greene: People will know that paracetamol is one of the most commonly used medicines and is available to buy over the counter. Traditionally, up until last week, you could have purchased a pack of it for 79p or whatever in a local pharmacy; this week, the price that pharmacies are being charged, through the supply chain, for the same pack is approaching £2·00, so it is not sustainable for us to sell it at 79p. We will always work in the interests of the patient, but that is part of the reason why the price has gone up. There are global issues at play because of problems in India with the supply of some of the core ingredients for paracetamol, and that has affected the ability globally to make paracetamol. Therefore, there is a supply issue.

It is affecting not only over-the-counter medicines, as we call them, but prescription medicines. We are seeing the price of some medicines rocket. We have to buy the medicines in at the price that we are charged, otherwise patients do not get those medicines. That is why pharmacies need certainty about the funding and the injection to support us. We cannot carry all of this uncertainty. We cannot carry the additional costs at this time when we have an underlying funding issue. Therefore, we have been in discussion with departmental officials about the immediacy of funding being released.

We just want to get on with the job of looking after patients. That is what we do, day in, day out. Pharmacy teams do not want to have to worry about whether their business is viable. With the increase in the cost of medicines and with the frequency of much-larger purchasing, many pharmacies are starting to hit thresholds whereby wholesalers are starting to demand payment in advance or on account straight away so that medicines can continue to be provided. There is a lot of uncertainty in the network. We need the investment to stabilise our network so that we can get on with looking after patients and not worrying about the prices.

Peter is a community pharmacist, and he will be able to tell you about the issues on the ground. I am happy for Peter to supplement and lead on any aspect of the day-to-day issues.

The Deputy Chairperson (Mrs Cameron): Before you come in, Peter, I want to ask whether there is any legitimate reason for the price of medications to rocket, in your opinion.

Mr Peter Rice (Community Pharmacy NI): There are a number of factors at play. A lot of medicines come from outwith this country. There are raw ingredient issues with paracetamol. There is also an issue with the availability of foil to seal the packs. If we cannot get the foil, the manufacturers cannot make it, and if they cannot make it, they cannot supply it. We are dealing with market forces. When there is an immediate global spike in requests for certain medicines and there is an insufficient supply, the market price goes up. It is outwith the control of pharmacies.

Mr Greene: This is where the public have a responsibility. There is a certain amount in the supply chain and, if the demand is such that that is swallowed up straight away, that is what causes supply problems. We need the public to pace their use of and requests for prescriptions.

The Deputy Chairperson (Mrs Cameron): Thank you for that. I know, from personal experience, that you cannot get paracetamol in shops now. That was so common but you cannot get it now. There must be people who are stockpiling it at home, and, obviously, you would discourage that, as we all would, to ensure that there is enough to go around. You mentioned social distancing quite a bit in your presentation. Is there much of a cost incurred by what you are doing in creating those physical barriers? Is there much of a cost to pharmacy to introduce these measures?

Mr Rice: The whole cost of it is borne by pharmacy. It is an individual business decision, and it has cost a few thousand pounds for each of my branches to put it in place. I felt that we had very little choice, and, in many cases, despite the recommendations coming out, people are presenting for triage at the pharmacy with coughs and high temperatures. We cannot risk our team being wiped out.

The Deputy Chairperson (Mrs Cameron): We should emphasise that the guideline is that, if you have a persistent cough or a temperature, you are not to go to a pharmacy.

Mr Rice: If you have flu-like symptoms, do not present at a pharmacy.

The Deputy Chairperson (Mrs Cameron): Do not present. It is good that we clarified that today again: you do not present at any GP, emergency service or, indeed, a pharmacist with those symptoms. [Inaudible.]

Mr Gildernew: I also worry that there would be issues with price. Across the world, Governments need to do more to ensure that key medicine is available. I have a couple of questions. It keeps leading back to here. Is the Committee Clerk there?

The Committee Clerk: Yes. I can read the questions for you, Colm. The first is: how could Community Pharmacy solve some of the issues that arose this week when GPs introduced the changes to prescription ordering arrangements? The second question is: how long do you think it would take to implement the measures of community pharmacies taking control of repeat prescriptions, as proposed by Gerard?

Mr Rice: A lot of our issues are about access to surgeries and communication lines. These are problems in the systems that have existed for years and are now being highlighted. We feel that we are very well placed to manage a repeat prescription service. Indeed, many pharmacists already manage this in GP surgeries. We need the enablers to let us do that. We feel that it would take the pressure off the surgeries and would quell a lot of the panic from patients who are trying to get through to surgeries but are clogging up much-needed phone lines. That would allow us to deal with the day-to-day repeats. I will ask Gerard how long it will take to implement.

Mr Greene: With the board and the Department, we are looking at potentially introducing a relatively quick version of a repeat dispensing-type service, but this highlights, as Peter said, that there is a system fault here. In Scotland and the Republic of Ireland, they have systems in place that allow the pharmacy to be authorised to dispense repeat medicines on a monthly basis for up to maybe six months or a year. That takes the pressure off the GP services; they do not need to be dealing with that aspect. Community pharmacy can then deal with the patient on a monthly basis. That interaction with the patient happens. It is not just about the supply; it is about the additional advice, the monitoring, the health and well-being, and about signposting if symptoms come up. That can be done in the community pharmacy. Community pharmacies are health hubs in local communities. They are where people go. Of the prescriptions that are dispensed, something like 60% are for long-term conditions, repeat medicines and so forth. A huge volume of work goes through GP surgeries that does not need to be there. It could be handled in community pharmacy. We know our patients, and, more importantly, our patients know us.

It is not rocket science. Elements of investment would be required. IT is certainly required. However, that could be fast-tracked through an initial COVID-19 emergency supply-type service. It would take the pressure off. Patients cannot get to GP surgeries. Pharmacies are asked to go to GP surgeries to pick up prescriptions, but, understandably, because of GPs' concerns, they have closed their facilities. That makes it difficult for community pharmacy. That stage is not needed. It should be held in the community pharmacy, and there should be electronic linkages with the GPs around it. It could be done in community pharmacy, and that would make life easier for patients. They could come into the pharmacy, as and when they need their medicines, within allotted times. That would help community pharmacy teams to plan the work that is associated with dispensing those medicines. At the minute, we have a surge, and everybody is looking for medicines all at the one time.

Everybody talks about flattening the curve. That aspect could be flattened relatively quickly. It needs to be prioritised. What we need to do here first is to stabilise community pharmacy. That is where the financial uncertainty needs to be addressed urgently, as well as the staffing issue around COVID-19 status. Those are my asks of the Committee and the Executive.

Mr Rice: May I just add to that? I operate a pharmacy in Dublin. We are not seeing the same run on the pharmacy in the South as we are in the North, because the South has that ability to manage supply without having to access health centres.

The Deputy Chairperson (Mrs Cameron): That is good to know. It is easy to forget that there are so many other health issues and conditions out there apart from COVID-19. If people do not get appropriate medications, and do not use them appropriately, that will also lead to needless hospital admissions. It seems to be a very good plan to enable pharmacists to provide that repeat dispensing. It is good to hear that.

Colm, have you any other questions that you want to put to the witnesses at this stage?

Mr Gildernew: I am OK at the moment.

Mr Chambers: In the past, I was told — maybe this is not correct, but it would be a very important bit of information — that, if no pharmacist is available on the premises, you have to shut. Is that still the case? By law, does a qualified pharmacist need to be on site while your door is open?

Mr Rice: Yes. There must be a responsible pharmacist on the premises or the shutter cannot open. That is why there is an urgency in getting testing, because if one pharmacist is [Inaudible.]

Mr Chambers: I support all that you said, but I will be a devil's advocate now. On testing, if a pharmacist or important support member of staff has reason to believe that they should self-isolate — they have symptoms, are taking responsible action and staying at home — does it really matter whether they know that it is COVID-19 or just a bad flu? If some mechanism is created whereby they can go and get tested, or the test can be brought to them, and it is found that they do not have COVID-19, you would not want that person with a bad flu or even a bad cold to come back to work, because it would be just as bad if other workers picked up the flu or a bad cold. What is the rationale behind someone who is self-isolating at home knowing whether they have COVID-19? There is no specialised treatment, so why do you need to know whether you have COVID-19? If it were me, I would like to know, and I am sure that you would as well, but I cannot see how it would allow people to come back to work immediately.

Mr Rice: That has a number of aspects. First, people are self-isolating whether or not they have symptoms. If one family member shows symptoms, the whole family self-isolates. That is a big problem. Secondly, if people, for one reason or another, want to come back and they have mild symptoms and are capable of working, we need to assure the rest of our team that they are fit to come back to work.

As you said, there is already a shortage of community pharmacists. If we cannot get those with mild symptoms, whether a cold, flu or other, back to work, those pharmacies close.

Mr Chambers: In terms of the surge in prescription medicines, you are talking about a 48-hour turnaround. We have all been used to just going into the chemist, sitting for five minutes and getting our prescription processed. It is a great service. Given that there are no medicines for flu, colds or COVID-19, why is there that surge in prescription medicines being issued? Is it just seasonal?

If I started to order repeat prescriptions every two weeks when he gave me a month's supply, my GP would quickly ask, "Why are you asking for these? We've given you a month's supply, and you only got it a fortnight ago." Do GPs not have a responsibility to control that? I do not know whether stockpiling of prescription medicines is part of the problem. It might be. Do GPs have a responsibility to try to curtail that a little bit and stop the surge of prescriptions being presented?

You talked about the economic impact. Nobody likes to talk about money. You are providing a service, but the reality is that if you guys are not making money and profit, you cannot pay the wages, the rates or the rent, and you are out of business. We have to appreciate that you are a business and you need that income.

You are allowing only a couple of people into your premises, and that is sensible. That must be having a pretty devastating effect on your turnover of ancillary products. Petrol stations could not exist if they sold just petrol, so they sell groceries, coffee and food. Pharmacies sell all sorts. You sell even grocery items: kitchen rolls, toilet rolls, if you can get them. There are also beauty products. That must be vital for your balance sheets. You have to get those sales, so you must be suffering a downturn in that. Just filling prescriptions is, I assume from what I have heard over the years, not going to keep your door open. You need those ancillary products. Would it be reasonable to say that the Government will have to — and maybe you alluded to it — give you a package to make up that shortfall of profit that you would normally get from the ancillary products and that you are not going to get at the minute? Anybody who walks into your place now, having been queueing outside and being one of three who gets in, they are not going to be strolling around the beauty section. They are in to get whatever it is they want, and they will be straight out again. I take it that would be a rationale for some financial help.

Mr Rice: Your first question was about the surge and there are a number of reasons for it. One is that people who have underlying respiratory conditions and may not need their inhalers on an ongoing basis are making sure that they have an inhaler that previously may not have been in date or that they feel they need.

The other problem is we are seeing an increase in quantity of medicines. GPs have to take contingency measures in case, in a month's time, they are not able to open their doors. There is a rationale to them trying to manage that. We on the other side are seeing that, as with people going to supermarkets and so on, people are worried that they will not get out. That is why there is a surge. A certain number of people are going out, reasonably so, right on their 28 days, whereas they might have let it lapse to 30 or 35 days. We are seeing people coming out more often to stockpile. In a lot of cases, it is prudent, because we may not be open in a month's time to serve them. That is the surge.

Our retail has nosedived. As professionals, we believe that the health of the public comes first. We have stepped up and taken that business hit because, in this crisis, we feel that the best thing we can do is support public health and try to take the pressure off. Unfortunately, that has come at a cost to our business. We would welcome any support that the Government could give.

Mr Chambers: We certainly cannot depend on your goodwill.

Mr Rice: Especially, given the last 10 years of insufficiency, where we have been running hand to mouth. We need that addressed now.

Mr Greene: What we see in the surge is people coming in and looking for the simple medicines that they can buy over the counter, paracetamol and so forth. However, the huge surge is down to people wanting another supply of their repeat prescriptions. The GPs do not know when they are going to be open again, so they are facilitating provision of the prescriptions. We are seeing that surge come through. It is repeat prescriptions. This is not about profit but about running costs. For pharmacies generally, 90% of activity or turnover, call it what you want, will be NHS-related. Retail is a very small proportion. When you look at the range of products in pharmacies, there is such competition with other outlets for those products, that it is just there as a space filler, in many instances. The NHS element is all-important.

As Peter says, this is about a profession that has patient care at its heart. We are managing a drugs bill of £400 million every year. That is £400 million worth of risk that pharmacists take on annually. They are managing the stock, the staff and the investment requirements, etc. As Peter says, this is against a backdrop of a £20 million per annum deficit. At present, pharmacists cannot pay wholesalers for their medicines, so profit is not where we are at of the minute. This is basic running costs, and that is why the injection of funding around the staffing costs, the additional measures, is required. It is also why there is certainty and support for the drug costs that we are going to incur. There are two elements to that.

Mr Chambers: I have one more question, Chair. Normally, my doctor will give me only a month's supply of what I want, and that is across the board. Are you saying that doctors are now taking a long-term view, and giving people, maybe, three months' supply? If that is the case, is it going to have a knock-on effect for pharmacists? I do not know what way you are paid. If you are paid per prescription that you assemble, if you are preparing a prescription for somebody with three months' supply, and they are not going to come back to you for three months, you will miss out on another two prescriptions that you may have been getting paid a fee for. In the long term, will that affect you?

Mr Rice: Yes, absolutely. There are two portions to our payment. The fee element, for processing the prescription, will be lost for the next two months. That has a big impact on us. You asked a question about the percentage of retail. Our turnover might be split 90/10, but retail has been shoring up a lot of our business. Even though the turnover on the prescriptions is a large part of the business, in profitability, retail is shoring it up. We now are starting to lose the fee element for the professional work that goes on, whether that is through one prescription for two, and when we lose that, it costs us, not today, but in the next two or three months, and that will cause a real problem.

Mr Chambers: Are GPs routinely giving more than a month's supply at the moment?

Mr Rice: Yes. We are seeing a move from, sometimes, 28 days to 84 days and 56 days. It is ramping up.

Mr Greene: The issue for the health service is that there is a greater risk of medicine wastage, once you start to increase the number of prescriptions and months that you give patients. It needs to be managed carefully. Community pharmacies are ideally placed to do that. We all have a responsibility. We are healthcare professionals. Yes, we have to make sure that our businesses and pharmacy operations are viable. At the moment, the profession is really struggling. It is on its knees, when it is trying to step up most. At this time, we absolutely need the support of the Assembly and the health service.

There are long-running issues with our funding. You can look at fees not being paid for a month or two, but the totality of the investment in pharmacy is wrong at the minute. It has been a long-running issue. We were due to speak to the Committee next week about that. We need to sort out the underlying issues, but, right here and now, the step up that community pharmacy is doing for the health service and the public here is incurring extra cost. It is incurring a lot of uncertainty as to pharmacists being able to honour their obligations with their wholesalers around medicines. There are also issues around our prescriptions being processed by the health service. That is a process that involves humans as well. That is why we need the certainty that our payments will be maintained here, as well as the additional resource that is needed. This is about continuing to try to provide the service; it is not, at this time, about profits.

Mr Carroll: Thanks, Gerard, for the presentation. Obviously, community pharmacists are doing an important job in this situation. We thank them for their role.

I want to make a couple of quick points. Testing is essential. I said during a previous presentation that I know people working in the health service who have to self-isolate because they may or may not have COVID-19. Some have partners who work in the health service; they also have to self-isolate because, obviously, their partner is showing potential symptoms. Those people could be back in our health service. I am sure that there is probably a similar situation with community pharmacists who are showing symptoms but have to isolate because they are following medical advice. They have to remain at home for two weeks because there is not enough testing ongoing. That is very concerning. Testing needs to happen as a matter of urgency. I echo your points on that.

You highlighted the problems with the pressure that GPs are under. I have received a few messages, even in the last few days, online from people asking me what they should do. Some are trying to ring through to their GP to get prescriptions. Could you give some practical advice to people who are trying to get prescriptions but whose GPs are overwhelmed? What should they do? I would like some general advice, please.

Finally, suppliers bumping up prices at this time is scandalous and repugnant. I am not talking about you, obviously. People should not be making massive profits in this situation. This is a public health epidemic. It is an emergency, and we should all be coming together. The fact that people are trying to profiteer off the back of this is quite concerning. We need to have a conversation about not acting in the interests of market forces; we should ask what is in the interest of good public health. A lot of stuff can be done around that. That is quite horrendous, to be frank.

Mr Rice: Gerry, you asked about responsible contact. The problem is that a lot of people are, quite rightly, trying to contact their GP for advice because they cannot present. As a result, they cannot order their repeat prescriptions. I had a case yesterday where a patient needed urgent cancer medicine. They had tried to contact their GP for four days in a row but were not able to get through, so they presented and said, "I am now out of my medication. Can you supply?". We do not have the facility to do that. We are in an emergency supply situation. There are issues around controlled substances. We are looking at those. We are in a similar position with patients who need quite urgent pain medicines. Some of the most vulnerable require compliant support; we try to keep ahead of the prescription so that we have time to prepare that compliant support package. I have a number of contractors who have contacted me and said, "Will we just dispense the compliant support because the patient needs it? We'll try to resolve the prescription issues later". The actual physical barrier is closed, and you cannot leave in paper requests, so the phone lines have become clogged. That is causing us issues. It is also causing us issues with clinical queries. If we are concerned about a patient or a prescribing matter and we wish to contact the surgeries, that avenue is not available to us now. That, obviously, will have impacts.

Mr Greene: As I said in my statement, we have been linking with the GP leadership bodies in Northern Ireland. They recognise the impact that this has had on community pharmacy being able to access the GP surgery for those prescriptions, for clinical queries, as Peter said, and for follow-up in any regard. They recognise that there needs to be a relaxation so that community pharmacy will not be overburdened at this time. I understand that there has been communication to practices around that but we really need to see that being fast-tracked on the ground, so that there is the facilitation of the community pharmacy contact as well as the patient contact.

We are dealing with a very difficult situation. It is evolving all the time, but it calls for leadership on so many different fronts. Pharmacy is stepping up here. It is looking now to the health service, to general practitioners and to the politicians to recognise that we are coping, want to continue and want to play our part, but we just need some certainty on the easement in getting patients' needs from the GP surgery, in terms of finances to ensure that we can continue to honour wholesaler obligations and that we have the additionality for the additional costs that we are incurring.

It is about all of those elements. The pharmacy teams are stepping up. It has to be a broad approach here to get the solution.

Mr Carroll: Peter, the clogging up of the system is very concerning. As I understand it, the advice is that if somebody living here is self-isolating for a week, they have to ring their GP to see if they qualify for a test. If the GP is clogged up because of people ringing in and trying to get repeat prescriptions, we face a situation, potentially, where those people might come down to a pharmacy or they might go back into work. That is a very worrying situation. Is there anything you think that the Department could do concretely to try and alleviate those particular pressures?

Mr Rice: What we really are looking for is a step change to allow us to manage the 60% who could be clinically appropriately managed in the pharmacy. If you can do that, it takes the pressure off that repeat prescribing, which does free up GPs' surgeries.

In response to your question about people presenting in pharmacies, just yesterday one of my pharmacists informed me that a patient, who had been tested positive, came in and said, "What do I do now?".

The message is not getting out quickly enough. If we can resolve repeat prescribing, and deal with that urgently, then those phone lines can be opened up, and people will, in the first instance, ask someone for advice, before they turn up for face-to-face advice.

Mr Greene: We are involved in various escalation planning with the board and the Department, and we are looking at a range of measures that pharmacy can step in to. The situation will evolve and maybe develop in more complicated ways, but we need the basic problems sorted out on the ground here.

My ask is clear: sort out the immediacy of the current problems that we have so that we are then equipped and able to step up when the escalation planning has to kick in.

At the minute, there is a lot of uncertainty. We really are looking to the health service, the Minister and the Executive to recognise that community pharmacy is in the middle of this crisis. We need support, and we need it quickly. I cannot stress enough that this is not about the end of next month; it is about this week. Our members need to be told, so that they can just get on with providing a service without the worry of asking if everything is going to be alright

Ms Bradshaw: Thank you, Gerard, and thank you for your leadership at this time. I called to a pharmacy on Saturday, and I saw at first hand the pressure that you are under. Community pharmacies specifically are doing a brilliant job at the minute and in the context that you have just had your ballot on industrial action. The pressures were there before this even started.

It is great that you are to come back next week and talk in wider detail. Just for today, you mentioned 20 pharmacists who are self-isolating. Is there any conversation with GPs about practice-based pharmacists being redeployed?

Mr Greene: Yes, and that is all part and parcel of the escalation planning. I think there will be a communication from the Chief Pharmaceutical Officer about people on the pharmacy register coming forward.

Ms Bradshaw: Ok, thank you. In terms of quantifying the additional hours, the renovation costs, is that what community pharmacists are doing at the minute, or are you firefighting?

Mr Greene: We are firefighting; it is just about the here and now, but those costs will be easily captured. It is not hard to quantify the capital expenditure that will be associated and the additional wage costs. I have been contacted by pharmacy owners who are in complete admiration of their staff for rallying round and coming in early, working through the evening and into the early hours and coming in on holidays. We are now looking to the centre to ask for support. This is what we are doing and this is what we want to do, but you really need to step in. We need a significant portion of that underfunding of £20 million as an emergency investment just to stabilise.

Mr Rice: It is one thing to talk about the extra costs now, but the increase in the minimum wage and the knock-on effect that that will have from 1 April on pensions was already going to cause a significant concern. We are probably looking at a 6% increase in our wage bills, with a minimal increase in our core funding. That was enough already to cause concern that pharmacy's lights would go out. With the extra wage bill, we really need some support now, or it will not be a question of whether we will close but a question of when.

Ms Bradshaw: Lastly, the previous two presentations focused on social care and nursing homes. How is that working out with delivery of blister packs? Is that causing even more frustration and chaos for you in making sure that those medicines are getting through to the most vulnerable?

Mr Rice: Absolutely. Blister packs are one of the most labour-intensive ways of managing our dispensing, and these are the most vulnerable patients. Nursing homes, obviously, require a lead time to access and prepare the prescription. As I said, we are not getting the scripts in a timely fashion. We do not have the people to process that extra workload, which is currently not commissioned and was done by pharmacy in support of social care. Those are the things that could potentially be lost first, and the ongoing burden for social care, which cannot facilitate without it, is a real concern for us.

The Deputy Chairperson (Mrs Cameron): On the back of Paula's point, are there individuals who could be upskilled and, by the relaxation of regulations, could be empowered to help pharmacists to deal with that? I am thinking particularly of the filling of blister packs. It is vital that the medication is right and has to be overseen, but are there people who could help to deal with this? Would that be recommended?

Mr Greene: Setting aside the current crisis, I think that the skill mix within pharmacies is something that we are looking at. There is a shortage of pharmacists in Northern Ireland. We released a report at the end of last year that highlighted the deficiencies in the number of pharmacists. It is about looking at the other members of the pharmacy team to take on additional roles, undoubtedly.

Possibly, as we go forward, in the immediacy of the COVID-19 situation, there may well be changes that the public will have to recognise that we have to introduce. That may be around elements of the blister packs and around the supply of some medicines. This is being done to try to maintain the core service of getting medicines to patients. This is where, I think, there is a societal role here. There has to be friends, neighbours and family members rallying round, and I think that we are starting to see that here in Northern Ireland. People will need more support with their medicines from family members and so on. It is a broad approach, but community pharmacy will continue to look after patients. We know those patients, and we know what they need. Whatever patients will need, we will prioritise.

Mr Rice: On upskilling staff, no matter how many people you get to fill the blister packs, every item must be checked by a qualified pharmacist. Yes, there is a value in upskilling staff to prepare, but it must be double-checked by a pharmacist before it leaves the premises.

The Deputy Chairperson (Mrs Cameron): That is right and proper. Thank you for that. Clerk, are there any questions or comments from Sinéad Bradley, who is working remotely?

The Committee Clerk: Again, Sinéad would like to thank you for your briefing and to thank community pharmacists for their service. She says that she shares the concern that, due to small staffing numbers, swift access to testing is required to keep the service functioning. She says that society as a whole is dependent on your network and your business being sustainable.

She has two questions. What attempts has Community Pharmacy made to date to ensure that the chemists and members of staff are enabled to exercise social distancing? Has there been any financial support from the Department to facilitate this? The second question is: in this emergency situation, can pharmacies access loose paracetamol that is not sealed in blister packs? She recognises that this is not ideal in normal times.

Mr Rice: You probably saw a piece in the news, during the week, about the measures that are being undertaken. In my pharmacies, I have implemented post office-style counters to allow social distancing. In other pharmacies, they have put demarcations on the floor at metre intervals to keep people apart, for example, they get people to stand on an X and stay away from other people. There has been control of entry into pharmacies, so maybe one or two customers are allowed in at a time. There are a range of things that are suitable for various pharmacies in various locations.

The funding has been borne by the businesses. Currently, there has not been anything met from the Department or the government. Sorry, can you read the second question again?

Mr Greene: It was in relation to paracetamol.

Mr Rice: Paracetamol is available in dispensing packs, but, currently, that is not a facility to repackage and distribute. We are looking at a service that allows us to repackage and prepare paracetamol for sale. Gerard will probably elaborate.

Mr Greene: The technicalities and legalities around medicines are such that smaller packs can be sold but larger packs cannot. Therefore, we are constrained by the legislation. There are workarounds being developed here at the minute to try and fast-track supplies of the packs that can be sold into community pharmacies. We are hoping that that comes through very quickly.

What all of this shows us is that, as a profession and maybe as a wider health service, we need decisions made quickly in this situation. I mentioned earlier that I was struck by one of the doctors in the World Health Organization who has been involved in pandemic planning and management across the world for the last 20 years, and he said that if you are looking for perfection, you will fail. Speed is of the essence. That is where we are now. We need speed on a range of things here. I am not going to reiterate them, but we need that speed.

The safety, health and well-being of pharmacists' patients is paramount. That will always be a given. Therefore, whatever adaptations are being carried out in pharmacies or in relation to the supply of their medicines, they are being done with their interests, health and well-being at the heart of it all. That assurance is there.

On the supply of medicines, we will try and facilitate the patients as best we can. As I said, we have no option but to buy the more expensive medicines in. We had no choice, otherwise, we would just say to the public, "We cannot get your medicines at the price that they are normally available at". That is where we are saying to the Department and the board that you need to recognise that we have costs in relation to the supply of medicines. We need assurances on that, and we need assurances around the additional costs. Social distancing and additional staff are two of those elements.

The Deputy Chairperson (Mrs Cameron): OK. Thank you very much, again, for coming today. We appreciate your concerns. It is good to have all those concerns on the record. I know that the Minister will pay attention, and we will ensure that we follow up all these issues with the Department. I wish you all the best. Thank you so much to you and all your staff who are pulling out all the stops to serve the community. It is greatly appreciated. Thank you very much, and thank you for your time today.

Mr Greene: Thank you.

Mr Rice: Thank you.

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