I REFER to the issue of separation of prescription and dispensing that has been in the news and mentioned by the Malaysian Pharmaceutical Society in a letter.
It is just too simplistic a view to claim that patients will get better healthcare merely by making it compulsory for medicine to be dispensed by pharmacists. Good medical care is more than just that.
The doctor’s responsibility to his patient is clearly defined in law, ie “in all matters dealing with the medical management of the patient”. The patient-doctor contract holds the doctor accountable for all that goes on with the patient during the initial encounter and even years after.
This duty of care includes taking a proper history, conducting a full physical examination, ordering appropriate investigations, making a diagnosis, prescribing and ensuring that the right medicines have been given, counselling, monitoring treatment and follow-up. It is a complete and continuous management plan.
In hospital-based patients, it involves a costly team consisting of nurses, pharmacists and other allied healthcare personnel. In the typical private outpatient clinic, the patient expects the doctor to provide the full management plan within the confines of his practice. Dispensing of medications is an integral part of this management plan.
The process of dispensing involves standard operating processes like retrieving, batching, packing, labelling and verification. These can be done by a properly trained dispensing assistant. In physician-based dispensing practices, the process of sighting, verification and counselling can be done immediately by the prescribing doctor. This cannot be done in off-clinic, pharmacy-based dispensing. Indeed, in many countries with existing dispensing separation, including Britain, there is an increasing call for physician-based prescribing.
In Malaysia, if the patient wishes, the doctor can 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 trained and can be trusted with the welfare of his patient. To do otherwise is a dereliction of his sworn duty and exposes the patient to unnecessary risks.
Those who claim that doctors do not know medicines because they only spend one year studying pharmacology are misleading the public regarding the medical curriculum and training. Most medical schools require at least one full year of basic pharmacology. Thereafter, medical students spend the next five to six years in applied pharmacology and therapeutics whereby each and every clinical case eventually ends up with questions focusing on diagnosis, treatment, choice of medicines, drug-disease interactions, and side-effects of medication. Even after that, in their trainee years, junior doctors undergo the same routine of grilling by their seniors and mentors. The same applies when they undergo postgraduate specialisation. In total, this at least 10 years of training in the use of medicines before they are certified to be competent for unsupervised practice.The pressure calling for compulsory separation of dispensing can be expected as megabusinesses have now moved in to corner the dispensing market. To turbocharge their business, compulsory separation of dispensing is the required booster.
Zoning and mapping has been done to identify and to cherry-pick areas where the pharmacy business will be most lucrative. In areas like the Klang Valley, no more new pharmacy licences will be approved. Eventually, the small independent pharmacy will be snuffed out leaving finally a handful of big players to control the market nationwide. The rural and outlying areas will remain underserved and neglected as they will not be commercially viable.This future dispensing landscape will not benefit the rakyat. In studies around the world, including in countries where there is dispensing separation, the direct cost of medicines has gone up significantly. There are no properly done Malaysian studies that show that costs will come down – in actual practice, costs will escalate.
We must preserve the existing one-stop system as it prioritises the rights and interests of the patient and ensures that the doctor continues to uphold his statutory duty to provide continuity of care. The commercial interest of big businesses should not be the determinant.
The renewed push for compulsory prescription is not for the betterment of patient care. There have been no proper studies done or adequate transparent consultation with all the stakeholders. Clearly, there is much commercial lobbying after the Health Ministry made a stand that dispensing should remain with the GPs.
DR STEVEN CHOW , President, Federation of Private Medical Practitioners’ Associations, Malaysia
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