by Mary Ann Sant Fournier BPharm, MPhil

President, Malta Chamber of Pharmacists

Introduction

In the present scenario of primary health care reform proposals and concern for health care system sustainability, not least the access to and costs of medicines in the national health service, the POYC paradigm has continued to evolve.

The Foresight study1 presented four possible future scenarios for community pharmacy as an integral part of the Health system in Malta 2010 vision (Table 1).

  • Business as usual: where current trends are pursued with no change in policy
  • Hard Times: things get worse but no catastrophic collapse
  • Onwards and Upwards: current trends are put into a better environment
  • Visionary/Paradigm Shift: successful public participation in policy allows pursuit of visionary/alternative directions

Table 1: The four scenarios for community pharmacy as an integral part of the Health

system in Malta 2010 vision

The present scenario may be considered to be at the third level, that is ‘Onwards and Upwards’, though some aspects of the fourth, highly desirable scenario (Visionary / Paradigm Shift) may be said to have been achieved.

 

POYC Implementation Timeline (December 2007 – Present)

The POYC scheme was implemented as a pilot project in December 2007, with an incremental approach, attaining roll-out by July 2008 in 28 localities in Malta, in 68 private pharmacies (n=207, 32.85%), in which community pharmacists were serving 25,000 registered, eligible, chronic patients (n= 130,0000, 19%); this figure to date increasing to 30,000 patients.

The POYC Standing Advisory Committee was convened in July 2008 and decided that, as provided by the POYC agreement2, the POYC pilot should undergo interim analysis; thus, further rollout to Iklin was temporarily suspended. At that stage, patient registration in Sliema had been completed.

An expected development, a direct effect of decentralisation, was the closure of the Mosta Health centre pharmacy in August 2008, resulting in pharmacists and other human resource re-deployment, after the POYC Unit invited remaining patients in the area to register with the pharmacy of their choice.

 

Interim Analysis

The Government and the partners made separate assessments. The former‘s assessment exercise was a rather unexpectedly long, internal, unilateral situational analysis (July 2008-October 2009).

Also, Government embarked on a reorganisation of the POYC Unit, appointing a Pharmacist Director. The Unit has since evolved into a fully fledged department with phased increased pharmacist and other supporting human resources, including managerial IT and financial audit staff.

 

Professional and Organisational Assessment

The Malta Chamber of Pharmacists and the Pharmacy Section of the Chamber of Small And Medium Enterprises (GRTU) immediately forwarded to the incoming Minister for Social Policy, a preliminary professional and organisational assessment document3 factually addressing the strengths and weaknesses of the POYC as implemented, with several proposals and recommendations for discussion and implementation, as an envisaged re-engineering exercise involving the three parties signatory to the Agreement.

POYC Workshops – Structured Dialogue

In the period August-October 2008, two cycles of small group dialogue meetings were organised (August/September: 12 meetings, 42 pharmacies, 18 localities participating in the first phase of the national roll-out; October: 3 meetings, 23 pharmacies, 8 localities in the pilot area). The format was of working luncheons for managing and locum pharmacists practicing in POYC pharmacies. Discussions were held under research conditions, with attention to confidentiality and data protection issues. An inclusive approach was adopted, urging non-pharmacist owners to participate. Participants were followed up by phone and email. The option of one-to-one meetings and support by visits to individual pharmacists and pharmacies were also offered and welcomed. Participants were invited to be proactive and present their recommendations to overcome challenges.

The objectives of the dialogue meetings were to:

  • listen to the individual and collective pharmacists’ experiences and issues, and to trouble-shoot where possible, immediately;
  • support pharmacists and pharmacy owners to resolve their issues, rendering the system as efficient and professional as possible;

The dialogue highlighted pharmacists’ professional and organisational issues, specifically, time constraints due to added administrative load, necessary computer software upgrades to a professional tool for more effective clinical interventions, and the maintenance of adequate medicines stock levels.

A meeting was also held in October 2008 with pharmacists piloting the new Web-based Dispensing Pharmacy System (WPDS) which introduced the electronic identification registration (e-id) for verification of pharmacists’ interventions in delivering a POYC service to patients. The WPDS has since been fully implemented in the 68 POYC pharmacies.

‘POYC is here to stay’ – Government

In meetings with the Parliamentary Secretary for Health and the Minister for Social Policy (September and November of 2008), the Government’s affirmative position on the envisaged POYC full national rollout was consolidated, but a realistic time frame was not established as this was subject to the proposed review of the social security entitlement legislation and pharmaceutical policy developments.

In this regard, an important meeting was held in December 2008 with the Director-General, Strategy and Sustainability and the Director of the Pharmaceutical Policy and Monitoring Unit to discuss aspects of medicines policy example, access to medicines, including innovative ones.

More recently, in October 2009, an important Continuing Professional Development event was held on the updated Government Formulary List4 addressing Formulary Management, Entitlement Control and Pharmaceutical Policy on Medicines Entitlement, together with the relevant legislative framework.

As envisaged, the POYC implementation has spearheaded the reengineering of the National Health Service medicines entitlement and other related policies and protocols, with the final objective being the introduction of a reimbursement system based on an EU model applicable to Malta.

Since February 2009, the POYC Standing Advisory Committee has resumed its regular meetings, addressing the pending issues, the single most significant one being the out–of-stock situation which necessitates a credible and lastingly effective solution. The Government is committed to resolving this matter and the partners have made short and long term recommendations.

In this scenario, progress in the national rollout of the POYC is envisaged to proceed to serve up to 50,000 new patients in the next phase.5

References

  1. Sant Fournier, Mary Ann (2004) Exploring Successful Scenarios for the ‘Pharmacy of the Patient’s Choice Project’: A Foresight Exercise. Oral presentation