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PHARMACISTS ARE STILL none the wiser as to how and when the government’s plan to roll out free Hormone Replacement Therapy (HRT) products for women experiencing symptoms of menopause will begin.
The outgoing health minister Stephen Donnelly announced that €20 million was being made available from January as part of Budget 2025 for the provision of state-funded HRT products, which would make them free for all women who have a prescription from their doctor.
The medicine-based treatment, which is used to relieve symptoms of menopause, perimenopause and postmenopause, is already free for holders of medical cards, but otherwise can cost in the region of €30 to €70 a month.
Under the new scheme, the products would be free of charge, but women who have a prescription from their doctor would still have to pay for their GP visit and the dispensing fee to the pharmacist.
However, there has been a delay in rolling out the measure which means women currently still have to pay for HRT products as pharmacies say they have not received details on how the scheme is supposed to work.
Pharmacists say the impasse is because they don’t think that the scheme should be described as ‘free HRT’ when women will still have to pay the dispensing fee, as well as for a GP appointment to get their prescription.
The Health Minister says that the scheme “has been available to be implemented since January” and should be rolled out now, despite this.
When the January deadline passed, the Irish Pharmacy Union (IPU) told The Journal that it had written to the Department of Health four times and held two formal meetings “seeking clarity on how the scheme is proposed to operate”, but had not received clarity on it.
Earlier this month, Health Minister Jennifer Carroll MacNeill said she had met with the IPU on 11 February and had “a good discussion” with them about the rollout of the scheme.
The Fine Gael TD said there had been a perception the medication would be “free entirely” and that the Government would cover the dispensing fee, but this is not the case.
“It was an effort to begin to do something, but there wasn’t agreement with the pharmacists that they would dispense it, and so it wasn’t implemented, even though it has been available to be implemented since the beginning of January,” the Minister said.
Dr Caoimhe Hartley established the Menopause Health clinic in Dalkey in 2021. She is also the clinical lead of the Complex Menopause Service at the Rotunda Hospital.
She told The Journal that the fact that a free HRT scheme is even being discussed is “brilliant”. However, she said there is “a lot of confusion” amongst her patients over the status of the scheme as it stands, which has led to “frustration”.
“We still have patients who are coming in, and we’ll talk to them about a prescription, and we’ll give them a prescription, and then they’ll ask us, ‘I presume this is free?’. They will have heard about the free HRT scheme, but they’re not aware of the fact that it hasn’t actually come into action yet.
“Five or six years ago, it wouldn’t have been on anybody’s radar to talk about having any sort of HRT scheme. The clinic that I run in The Rotunda, that’s a public clinic. That would not have existed five or six years ago. Something has definitely shifted, which is really positive.”
A spokesperson for the Department of Health told The Journal that it has engaged “extensively” with the IPU in relation to the rollout of the scheme, and that it remains “actively engaged on the matter with the goal to introduce this measure as soon as possible”.
Sheena Mitchell, a third-generation pharmacist, has run her own pharmacy in Dublin since 2008. She also hosts her own healthcare podcast.
Speaking to The Journal, she said pharmacists flagged that there were problems with the scheme from the time it was first announced.
“The biggest problem initially was in the naming of the scheme because it was inaccurate,” she said. “Calling it free HRT is misleading to the patient, and it’s us that are patient-facing.”
Mitchell said the name of the scheme had “caused a lot of confusion” for some patients, who thought that it would be the same as the free contraception scheme, which covers the cost of both GP visits and dispensing fees.
“It’s not free for the patient to receive the HRT. Patients have to pay for their GP consultation, then they have to go into the pharmacy and pay the dispensing fee. There’s a whole myriad of ways where the costs actually do significantly rack up for the patient.”
Consultations with GPs can cost between €50 and €70, while pharmacy dispensing fees can vary depending on the relevant reimbursement scheme.
She also said there was “zero consultation” with the community pharmacy sector before the measure was announced, adding that they have yet to receive a list of medications that would be included under the scheme.
“A policy was made without an implementation plan, so the stakeholders weren’t engaged. We heard about the scheme at the same time as the media, and ergo, there is no structure in place to facilitate the scheme.”
As a community pharmacist, I can tell you now that I haven’t received a single notification in the form of email, letter or phone call from either the HSE, the Department of Health, or the Minister in relation to the scheme since it was announced in the media.
Mitchell said the scheme is “a real missed opportunity to get equality among women of all different age groups when it comes to hormonal care.”
“For me, it’s not about the women who are already buying HRT. It’s about those women who aren’t accessing HRT now because of cost considerations,” she said.
Around 80% of women will experience one or more symptoms of menopause. Hot flashes, night sweats, low mood, brain fog, sleep disturbances, joint pain and urinary tract infections are just some of the symptoms associated with menopause.
“This reflected an opportunity for those women to be brought into the healthcare system and to have their issues addressed, but unfortunately, they still can’t afford to go to the doctor, and they still won’t be able to pay the pharmacy fee,” Mitchell said.
“The barriers exist, and it doesn’t represent equity or equality… It’s a further break in trust with our health service.”
Dr Hartley said that HRT is “the most effective treatment when it comes to managing a lot of the symptoms of menopause”.
For the 20% of women who get really severe symptoms of menopause, she said HRT can be “completely life changing for them and give them back their quality of life that they may have lost”.
“That’s the issue. When we have women on HRT, and it has changed their life, not being able to access it, either because of the financial barrier or because the thing that they were taking isn’t available anymore in the pharmacies, is really difficult and really detrimental to their quality of life and even their health.”
Kathy Maher, a pharmacist in Duleek, Co Meath and chair of the IPU’s Pharmacy Contractors Committee, told The Journal that the IPU was “fully supportive” of the Government’s commitment to the scheme when it was announced last October.
“We saw the difference that the contraception scheme made to women’s health, and we can see what a difference a free HRT initiative would make,” Maher said.
However, from the outset, she did not expect that the scheme would be up and running by the “ambitious” January deadline.
At the minute, there still isn’t any IT system in place for us to seek reimbursement of product. We’re not sure yet if there needs to be further legislation. There’s still no clarity in terms of the product that will be applicable.
According to Maher, the lack of an IT system is the most limiting step in implementing the scheme. When the free contraception scheme was announced, it took nine months to get a system in place, she said.
“From a public point of view, it’s hard to believe that there are actually 22 different medicine schemes by which pharmacies operate, and each one of them have different reimbursement rules of how we interact with the State and claim product payment. How the IT system would work for HRT hasn’t been made clear yet.”
HRT products are currently dispensed under two schemes. The General Medical Services Scheme (GMS) applies to those with medical or GP visit cards. However, if the product is not licensed in Ireland, there is no guarantee that it will be reimbursable for pharmacists.
The Drug Payment Scheme (DPS) sees the patient pay a maximum of €80 per month for medicines. The pharmacist receives the reimbursement price for the drug and the dispensing fee under the DPS.
If a patient is not spending more than €80 per month in their household, they are not eligible for the DPS as they do not meet the threshold. In this case, they pay privately.
In the Programme for Government, the coalition states that it will “streamline community pharmacy reimbursement procedures” and “review the pharmacy fee structure”.
Earlier this month, the Health Minister said the scheme has been “available to be implemented since the beginning of January”.
But Sheena Mitchell said that as there has been no communication in relation to an IT system, pharmacists have “no way” to administer the scheme.
“It just seems quite ridiculous that they’ve rolled out a scheme where they’re going to have to make another additional reimbursement platform, and that hasn’t been developed yet. Community pharmacists have certainly had no correspondence about it.”
Along with the delay in the rollout of the scheme, pharmacists have also been grappling with supply issues surrounding HRT products over the last three years.
While estrogen gel and progesterone are currently not affected, HRT patches have been “incredibly difficult to source for probably the last nine or 10 months”, Kathy Maher said.
The supply of products has been a bigger difficulty, and I would say at times, has been at crisis level.
“What can happen is one product might go into short supply, everyone has to switch to another, and then the demand on that product is extreme, and then we have to switch back.”
The Health Products Regulatory Authority (HPRA) told The Journal that there has been “intermittent supply” of some HRT products over recent years both in Ireland and abroad “due to a significant increase in demand and manufacturing issues which are limiting the ability to meet this increased demand”.
Dr Hartley said the shortages is currently “a much bigger issue than the cost” for her patients.
“We’re giving patients a prescription and we don’t know what’s available at any given time, and we also don’t know what’s available in one part of the country versus another.”
Maher said that healthcare professionals have worked hard in recent years to break down the stigma surrounding hormonal health and menopause care and symptoms, which she said can be “really debilitating” for women.
“The reassurance and the validation that they get from being heard is really important. But when there’s no continuity of product to treat, or perhaps for some women, HRT is not suitable or appropriate, they still have to manage their symptoms.”
When pharmacists do have to source unlicensed medicine due to supply issues, the State will not cover the cost in some cases as the product is not licensed in Ireland, Mitchell said, adding that dispensing fees can vary from pharmacist to pharmacist.
“For some women, it could be €8 a week on three items. That’s €24 a month, and that might be the choice between that and sports club for their child, or a new pair of shoes,” she said.
“Unfortunately, a lot of women can’t actually afford that and they will put themselves far down the priority list.”
The IPU has called for an increase in the fee to €6.50 per item of medicine dispensed under the community drug schemes.
“Now, on average, we get something like €4.34. We are so far behind and it’s just impossible to make ends meet,” Mitchell said.
Myself and my husband are husband-wife operators and there are months where I don’t take a wage so that I can pay my staff. That’s the reality.
Maher said that as the manufacturers of medicines not licensed in Ireland don’t have an agreement for the cost of the medicine with the State, those medicines can fluctuate in price.
“We just need to make sure that pharmacies are reimbursed at the price that they pay.”
She said the IPU is ”looking forward to ongoing collaboration with the Minister and her officials within the Department to get a proposal that will work for women”.
While she said that no deadline has yet been set for its implementation, she is “hopeful” that everyone is “focused and working in a collaborative fashion in the weeks to come”.
Dr Hartley said that offering clarity on when the scheme will come into effect needs to be prioritised.
“We have to start giving people some certainty about what’s happening, because the confusion around all of this is, together with the shortages that we talked about, immensely frustrating for women. Not knowing.”
In a statement to The Journal, a spokesperson for the Department of Health said both it and the HSE have engaged “extensively” with the IPU in relation to “the practical rollout of this measure, which was intended to commence in January”.
“Last month the Minister met with the IPU to discuss ambitions for expanding and reforming community pharmacy and on progressing the HRT initiative. The IPU committed to coming back to the Minister regarding the introduction of the HRT scheme, they have done so, and we remain actively engaged on the matter with the goal to introduce this measure as soon as possible,” the spokesperson said.
They said the free HRT scheme “represents another step to widen access to and reduce costs associated with menopause related treatments and services and follows on from all the other developments that have taken place over several years”.
“Reimbursement support for this new measure will be available to participating pharmacies from the date of commencement,” the spokesperson said.
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