For anyone who has read the Disability Discrimination Act 1995 – and I warn you it’s not a riveting read – it appears that for most recipients of MDS trays, there’s no legal or professional obligation to provide anything other than a normal service, says Terry Maguire…

“It’s a mess!” a defiant contractor concluded after a noisy, mostly incoherent, rant that more or less summed things up for the rest of us.

It had been a busy night of online meetings and we were tired. A Zoom, hosted by our health board, the Strategic Planning and Performance Group (SPPG), started at 7pm and this was followed by a Teams at 8.15pm organised by Community Pharmacy Northern Ireland. The main focus of these hurriedly arranged meetings was to clarify and explain the emerging adherence service.

Judging by the in-meeting 'chats' and follow-up questions, profound ignorance prevailed. Adherence support is now a core service in Northern Ireland; we must provide it. Is it different to what we have always done? From now on, who should be getting medicines in monitored dosage systems (MDSs)?

An increasing number of patients get their medicines dispensed in MDSs. The only remuneration, until recently, was indirectly from multiple dispensing fees.

Initially the multiple dispensing fee was the same as the ordinary dispensing fee (£1) but long ago, SPPG reduced it to 40p, yet we sheepishly continued to provide MDSs with a willingness to accept a cost on our businesses rather than a loss of patients to competitors.

The numbers are significant; last year we dispensed 42.5 million prescriptions with an additional 17 million multiple dispensing fees - most of these for MDSs. It is growing out of control and contractors increasingly complain they are not being paid to provide MDS trays while forgetting that, officially, no-one ever asked them to.

Multiple dispensing fees were not designed for adherence support, so a change to the Drug Tariff on May 1 restricts instalment dispensing (attracting multiple dispensing fees) to medicines of misuse/abuse potential.

The adherence service is now funded by an £18 million annual budget. The business case was, it seems, justified under the Disability Discrimination Act (DDA) 1995 and, accepting payment, contractors are required to “make necessary adjustments” to support patients with “disabilities” take their medicines.

Guidance produced in May is based primarily on the Act and is, to say the least, vague; deliberately vague, I suspect. SPPG seemed worried that when multiple dispensing fees are removed, contractors might choose to stop providing MDSs. MDSs are key to getting elderly patients out of hospital and keeping them out, as home helps will not administer medicines unless provided in MDS trays.

There was more than an implicit, yet vague, threat in recent SPPG correspondence that pharmacies were, under the DDA 1995, “legally” obliged to provide adherence support and failing to comply could be censured. Where you might argue – no-one likes a bully – it seems contractors are unlikely to stop MDSs anytime soon.

In light of the changes, I have reviewed all my MDS patients. I estimate that only 10 per cent would qualify for support under the DDA 1995 as there is the small matter that 90 per cent currently getting MDS trays could not be in any way defined as “disabled” and, therefore, I'm not obliged to make any “reasonable adjustments” for them.

This may seem a harsh and uncaring assessment but they do not have a “physical” or “mental” impairment that is “substantial”, “adverse” or “long-term.”

Notwithstanding this minor problem, to comply with the Act, the provider of a service is the only person who can make the assessment of “reasonable adjustment.” A Health Trust cannot demand an MDS for a patient so that they can get out of hospital.

Nor can a GP or a caring family member insist that a MDS tray is supplied. So, for anyone who has taken the time to read the DDA Act 1995, and I warn you it is not a riveting read, I would contend that for most current recipients of MDS trays, there is no legal or professional obligation under Act to provide anything other than a normal service.  

In the first week in July, I got a call from the Belfast Trust asking if I would provide an MDS tray for a patient who has been with me for over 40 years. I said I would not, given that, in spite of her advanced years, she was well able of taking and looking after her own medicines.

Later that day the patient rang to say that under no circumstance would she be requiring a tray and that, if she needed one, she would ask herself. The Adherence Service is a mess but not for the reasons my colleague at the meeting thinks.

I will gladly take this funding while slowly reducing the number of unnecessary weekly MDS trays with all the attendant resource and risk implications for my already overstretched business.

I will, of course, for these patients, record and provide other “reasonable adjustments,” thus ensuring this real income stream keeps flowing for this vague service.

Terry Maguire is a leading community pharmacist in Northern Ireland.