17 Aug, 2014
Is the call for the separation of prescribing and dispensing roles in healthcare a positive step for patients?
A DOCTOR’S duty and responsibility to his patient is clearly defined in law: “… all matters dealing with the medical management of the patient shall rest in the hands of the registered medical practitioner.”
In this respect, the continuum of care from the moment a patient consults a doctor for a medical complaint, all the way to treatment and the eventual response and recovery to treatment or otherwise, is and shall remain as the duty and responsibility of your doctor.
Patients expect this basic requirement from their doctor-patient relationship.
The act of prescription and dispensing is an integral part of this continuum. It is also the statutory duty and responsibility of the doctor to see that this is done correctly.
In our existing healthcare landscape, the doctor may opt to delegate the act of dispensing to a pharmacist. He will only do so if he is of the opinion that the pharmacist is properly qualified, trained and can be trusted with the welfare of his patient.
Likewise in general, doctors will only agree to this separation provided the system in place has proper safeguards and regulations to minimise dispensing errors and harm to patients.
To do otherwise is a dereliction of his sworn duty and exposes the patient to unnecessary risks.
Why all the hype?
The recent hype calling for separation of roles is an expected development as mega businesses have now moved in with the objective to corner the dispensing market.
Let us be clear about this. This is purely a business move to prepare the groundwork for a protected oligopolistic dispensing system for the future.
There is no basis or need to denigrate the role of doctors, as well as their training and expertise in prescribing and dispensing medicines.
The principles of good medical practice in this respect is also clear. It is also the duty of the doctor to know his medicine, and how it impacts his patients in all aspects. Failure to do so opens the doctor to civil negligence action and prosecution.
Separation of prescription and dispensing – is it safer?
Research done in the US and UK have also clearly indicated that errors in dispensing by pharmacists are just as serious in systems practising separation of roles.
In their memorandum presented to the UK Parliament in 2009, by Professor Bryony Dean-Franklin and Professor Nick Barber, dispensing errors were noted to account for 3.3% of all items dispensed and up to 9.8% of dispensed items in secondary care.
Indeed, in the UK, the government had found it fit to have criminal liability for dispensing errors. Pharmacists in many countries also are required to take up professional indemnity insurance.
Is the dispensing pharmacy landscape in Malaysia ready for such important changes?
Studies in the US have estimated that the rate of dispensing errors in an ambulatory setting can be up to 24% of prescriptions. In 1999, an investigation carried out on 51 Massachusetts pharmacies in Boston revealed that 4% of prescriptions dispensed by community pharmacists contained errors, of which 88% of these involved wrong drug or strength.
Clearly, dichotomy of prescriptions and dispensing is not a proven safe option for the Malaysian public.
Is physician-based dispensing better?
The physical act of dispensing involves rather standard operating processes like retrieving the right medication from storage, batching, packing, labelling and handing over to the patient.
These are things that a properly trained dispensing assistant can handle.
In physician-based dispensing practices, the process of sighting and verification can also be done immediately and by the prescribing doctor. This cannot be done in off-clinic pharmacy-based dispensing.
In all proper medical consultations, the process of counselling of medication would have already been done by the prescribing doctor at the time of consultation. This would have included proper dosing, drug-to-drug interactions, allergies, interaction with food and other relevant details.
It would also encompass how the dosing, indications and contra-indications relate to the patient’s personalised medical details like status of blood, kidney, liver and other vital organ functional status.
All these are part and parcel of proper medical training of a doctor.
Without the complete medical information of the patient on hand, the dispensing pharmacist will unlikely be able to do better than the dispensing doctor.
Should doctors continue to dispense?
We have yet to see for ourselves the proposed Pharmacy Bill, which is due for tabling in Parliament. We can expect this to be soon as the Dasar Ubat Nasional (DUNAS) is scheduled for full roll-out in 2015.
Central to everybody’s concern is the constant unhealthy lobbying for separation of prescription and dispensing in the build-up to this Act.
When the dust finally settles, even the poor independent pharmacist practices will themselves be squeezed out of business and the patients and public will be left to the mercy of mega oligopolistic pharmaceutical chains.
It is also clear that even with the proposed new Pharmacy Act, doctor’s prescriptions and dispensing duties remain unchanged.
The statutory duty of the doctor to dispense is clearly stated in the Poisons Act and the PHFS Act 1998/Regulations 2006, and shall remain.
We expect new regulations that will try to even the playing field between the dispensing pharmacists and doctors. It will, however, cut both ways. Would the public like to see doctors’ clinics dealing with OTCs like shampoos, soaps, toiletries plus all the trims and frills of the high street pharmacies?
Instead, the proposed Act should focus on the provision of common platforms where doctors and pharmacists can mutually work together to minimise errors rather than create unnecessary turf-protecting silos.
More stops, more cost
In a private clinic, the income from dispensing is an essential component to meet the running cost of providing the service of a one-stop treatment facility.
Historically, private doctors have been providing a single package fee for their services and medicines. With this system, one doctor with one clinic assistant can cost-effectively look after the basic medical needs of thousands of patients.
This has worked well to control the cost per visit for patients. No other system can be more cost-effective than this.
In the majority of cases, the doctor’s professional fee in these package bills was and remains to be really very nominal.
Even today, doctors are continuing to subsidise the cost of medicines from their professional fees.
The Federation will continue to champion our existing one-stop consultation, prescription and dispensing system for the convenience and cost-effectiveness for the patients.
Indeed, most of our patients, including those from other countries, like the one-stop facility.
There is no evidence whatsoever to suggest that separation of roles in the Malaysian healthcare scenario will be any better than what we have existing now.
A dichotomized system has also been shown to increase rather than decrease the cost of care and is not patient-friendly.
Imagine a mother with two feverish fretting kids in tow, sick and vomiting, risking life and limb crossing the crowded streets of KL or PJ looking for a pharmacist to fill their prescription when they could have easily sorted everything in the doctor’s clinic.
It is thus not in the patient’s best interest. The choice of where to get her medications is the right of the patient. It is not in the patient’s interest to take away this right.
We must preserve a system that prioritizes the rights and interests of the patient and ensures that the doctor continues to uphold his statutory duty and responsibility to provide continuity of care.