Separation of dispensing rights – start in major towns first

Previously, when doctors were accorded the legal right to dispense, there were very few pharmacists and pharmacies in the country. However, this is no longer the case.

There are already more than 6,000 pharmacists registered with Malaysian Pharmacy Board. More than 500 new pharmacy graduates are added to the nation each year. As such, the issue of a shortage of pharmacists should not arise.

A pilot scheme on dispensing separation can be started in the bigger towns such as Kuala Lumpur, Penang and Johor Bahru. Following this initial exercise, pharmacists will be encouraged to set up even more pharmacies in major towns as well as expand their services to the rural areas in anticipation of the expansion of dispensing rights out of the major towns. Exemptions can always be given to the remote areas that have none or very limited access to pharmacies until the situation improves.

Some have pointed out that pharmacies are not open 24 hours a day, unlike clinics. However, there are very few of these 24-hour clinics, and, even then, many patients are seen going to the emergency departments of hospitals instead. The Malaysian Pharmaceutical Society immediate past president, Mr John Chang has already indicated that if a clinic can open 24 hours, so can a pharmacy, and that this is merely an administrative issue driven by the current doctor-dispensing market.

One doctor had previously indicated that leaving dispensing with the doctors is economical and entails a lower risk of mistakes. CAP begs to differ.

Our surveys have shown that the prices of drugs sold at pharmacies are reasonable. In addition, as pharmacists are trained in the area of dispensing and can monitor for prescription errors and drug interactions, there will be a lesser chance of mistakes and adverse outcomes of medication.

Doctors do not, or at least should not, make exorbitant profits on medicines. As such, as far as monetary benefits go, the doctors should not feel too much of a loss.

In fact, the doctor would make more saving now as he will not have to employ and train dispensing staff, thus reducing staffing costs. The rooms or the areas previously used for storing medicines and dispensing will be cut down, and can be converted into more treatment rooms or even better waiting areas for patients. The doctor will not have to worry about dispensing errors which can be a nightmare.

One key role that pharmacists can and should play in the private sector is to screen for prescription errors. This role is currently carried out very effectively by pharmacists in hospitals. This is attested by a letter from a pharmacist in a Government hospital, which appeared in the press last year.

The writer states, “If any error is noted, the pharmacist calls the doctor, informs him about it and corrections are made to the prescription. This is what we call an intervention and it will be recorded. Interventions are made every day on prescriptions from doctors and trainee doctors. If the public were privy to the types of interventions the pharmacists make every day, the public would be more supportive of the proposal to separate the dispensing function from the prescribing function”.

Errors in prescribing do happen – under- or overdosing, writing a wrong dosage regime or prescribing drugs that adversely interact with each other, or are not suited for the patient’s age – among others. These errors, which might give rise to serious health risks to patients, can be spotted by a pharmacist in advance. Doctors in private clinics are dispensing without this added benefit to patients.

Based on information that we have previously sought from the Ministry of Health, it is the clinic doctors themselves who must dispense the medication directly to their patients. Clinic assistants, who have no formal training, are only supposed to help with the preparation, mixing and labeling of medication. Even these activities, according to the Ministry of Health, should be under the direct personal supervision of the doctor concerned.  But how often is this case on the ground?

Dispensing is a specialized area and the potential for error is very high when untrained staff take on the role of dispensing. Furthermore, patients might not receive proper instructions on how the medication is to be taken, the precautions that are necessary, and information on side-effects or drug interactions. Patients should not be exposed to these risks.

There may be some pharmacists who abuse the system. However, with the dispensing separation, the Pharmaceutical Division can now focus on this group when it comes to regulation and enforcement.

At the same time that the initial pilot project is being implemented in major towns, the Ministry of Health should initiate steps making it mandatory for doctors to give patients itemized billing as a routine procedure and to write their prescriptions using the generic names of drugs.

Letter to Editor, 10 July 2009