In this article, I as a humble small town General Practitioner, will attempt to provide credible grounds as to why doctors should preserve the prescription and dispensing duties in Malaysia, and also why Dispensing Separation is not without many pitfalls. I am going to divide our discussions into 5 major topics:
1. Where do we stand now in ranking of national primary healthcares?
2. Does DS save costs of total national healthcares in Malaysia?
3. What are the other controversies around Dispensing Separation?
4. Doctors in Malaysia are not alone is questioning Dispensing Separation. UK and US studies
5. What we think is best for the healthcare of the country.
6. The consumer groups that are against DS.
What is happening now?
Dispensing by pharmacist is akin to the depiction here, where the horse is the doctor.
The Malaysian Pharmaceutical Society have been pushing hard for the dispensing of medications to be handled solely by the Pharmacists with the tacit approval of the authorities. Things have come to the fore lately over likelihood of Pharmacy Bill which being tabled in the Parliament in April 2015; however this was recently denied by the MOH and MMC.
Dispensing Separation has been hotly debated by both divides of the healthcare profession, ie. the doctors versus the pharmacists. More than 95% of the Pharmacist support it; while most of the doctors are against. This article is about doctors’ point of view : why are we against it so vehemently.
The public may think that doctors are trying to protect their rice bowl; rightly so because in this critical issue is a matter of doctors survival, not commercial monopoly. However, beyond that point, there are more to the major issue than meet the eyes regarding the critical welfare in the health of the consumers. At the heart of the issue, is whether the citizens of the country will benefit from the system, or will it cause irreversible hardships for decades to come ! Is DS better that Doctors’ dispensing ?
MPS has been spearheading the promotion of DS, mainly on 2 premises :
1) It saves costs;
2) The safety of Pharmacists are more assured.
It would seem that these 2 claims are true. However, searches for studies based on outcomes of DS in those countries which have had it for decades suggests strongly that this system comes with numerous major problems which means that the risks and harms seem to offset the gains.
Where do we stand now ?
We are currently ranked 3rd in the whole world as being the best in primary health care, as posted in MOH facebook site.
Are doctors really unfit to dispense ?
Malaysia has among the best population primary healthcares in the world. Even the the Indonesians with their DS system at home and the Phillipiens are flocking to our shores for better cares. The primary care system has a place of merit in the system because we have sufficient number of private GP clinics throughout all corners of the country to provide community cares regardless of how rural the areas are. This big advantage is unrivalled by the pharmacists which are set up mainly in urban areas out of commercial consideration. While GP practice in Malaysia is not without faults, the deficieny in dispensing is totally and easily remediable. With better post graduate training and upgrading of dispensing professionalism, GPs can remain the best healthcare provider in the country for decades to come. National guidelines are available to enhance such dispensing performance across the country. Doctors can even use technologies such as Point of Dispensing softwares as safeguard to dispensing, which in some studies show greatly improve error reductions. By maintaining inhouse dispensing in the clinics, there is no upheaval in system change, no social cost to bear, no monopolistic manipulation by third parties which may wreck the system.
Is DS a panacea to the ills in healthcare ?
We the general public as well as all stakeholders have to realize that up to now, the available information show that the impact of the existing eight systems of DS practiced internationally have not been well studied. So far all have not been proven to be better than doctors’ dispensing in terms of total social and healthcares outcomes, although improved outcomes have at times been shown in drug expenditures alone.
Therefore, DS system is probably an unproven system which is fraud with complexities and complications. An example of interest is that almost half of the population of Japan are still questioning if DS truly bring worthy positive outcome despite having it for already 28 years.
We will see from the following questions as to why DS is probably not the best solution to the ills in our national healthcare :
Does DS save costs?
Before we go further into this aspect of DS, we need to answer the question of whether GPs are truly the cause of rise of healthcare costs in Malaysia ?
Many communities, Pharmacists community included, have directly or indirectly insinuated that for long time that GPs are the cause of increasing cost of healthcares, thus misleading the public and the policymakers. The fact is that the costs had been spiraling out of control mainly to the the costs of hospitalization, while costs of cares by GP is but a small portion of cost borne by the general population. GPs have been made the convenient scapegoat (no thanks to the past disunity among doctors) so that DS can be justified without strong reasons. Overall cost of healthcare by GPs have been minimal due to abnormally low consultation, absence of prescription fees, minimal inflation of the prices of generic medicine, passing of purchase discounts from suppliers to the consumers and also reducing costs of transportations due to one stop centre services provided by doctors. The inflation rate of private GPs cost is about 1-2% per year, which is way below national inflation rate. Some doctors hardly increase their consultaion fees over the years or even decades, and some MCO/TPA forcibly maintain the low fees for numerous years. The inflationary increases are mainly due to pharmaceutical companies increasing their prices, but the GPs generally would try to minimize that increase by bulk purchasing due to competition among practitioners.
Does DS save cost of total national healthcare ?
It is true, by means of bulk purchase and sales especially by the few giant pharmacy chains that dominate the market, that drugs costs and sales prices would drop at the retail outlets. However, this leads to rebound effects. The total cost of healthcares (costs of consultation, dispensing, transportation and ancillary services) has been shown in studies in countries such as UK, Taiwan, South Korea and Hongkong to be either the same, or increased. The government in Korea attempted to force the comprehensive DS system down onto the people without prior informing and preparing the public for the change, as well as imposing low consultation fees on the doctors. The result was a national strike by doctors which led to government realizing its mistake and hence provided for an increased consultation fees. It is the same for Hongkong; the people did not realize that the inevitable increase in consultation and other fees would either make cost not only either unchanged or even increased. The Taiwan government was more proactive in increasing the fees before imposing DS. A few years ago, the government of Taiwan had to create another supplementary taxation in the form of national fund as the existing fund was found inadequate; this suggests that the costs have not been properly contained.
So, DS indeed has been shown to be unable to contain the overall costs of national healthcare.
Can Doctors’ Dispensing contain the cost of total healthcare?
The issue at heart is that doctors’ in many countries, including those prior to DS being introduced, is the low consultation fees. In Malaysia, it is not uncommon to see doctors only charging RM10.00, up to RM 20.00, per consultation, even for many years without change and regardless of quality of cares. This is nothing short of being pathetic. Many of the TPA/MCOs’ have been exploit this anomaly by forcing doctors to accept this in the panel contracts. Thus, doctors would have to survive on earning some 10-30% more from the sales of the drugs. Otherwise, doctors simply cannot survive; the private clinic healthcare would simply collapse.
However, if doctors are allowed to charge a more reasonable consultation rate in line with inflation, the cost of drugs will definitely fall. Hence, the cost of total healthcare would either remain the same or would even fall. This is the very reason why the Ministry of Health must take upon itself to allow implementation of controlled and fair consultations fees acceptable to the people and the doctors which takes into consideration inflationary rates to help keep overall costs manageable.
Here are quotes of studies in Australia and UK which contradict the claims that Doctors’ dispensing are invariably more costly:
“Australia : Contrary to overseas findings, we found no evidence that Australian DDs overprescribed because of their additional dispensing role.”
UK : Dispensing practices have been prescribing and dispensing subject to the scrutiny of our local primary care organisations for years. Thanks to this external scrutiny of our NHS dispensing activities, there is ample evidence that dispensing doctors do not prescribe expensive products to make extra profits.
Why is maintaining the Doctors’ Dispensing the better option in terms of cost saving ?
Our country has a unique healthcare system recognized by UN as being among the most comprehensive and best system despite our lower ranking than other countries including Singapore which does not practice DS. A magazine survey in the USA has announced that we have arguably among the top 5 best system. Our private primary healthcare system have contributed to this enviable accolade.
Our country is blessed because health clinics, private and public, are found in any corner of the land. The quality is good, although enhancement is necessary for long terms quality of cares. So is the inhouse dispensing unit. The standard of the dispensing can be enhanced easily by employing in diploma level pharmacists, coupled with use of online technology.
In that way, doctors can lower the prices of the medicines while adjusting the consultation fees to those affordable standards.
Also, in this way, we can maintain as well as upgrade our unique doctors based system. Do we need to change the system by having dispensing separation? We can still have the best healthcare system in the world without breaking up a well tested system and trying up a new system frauds with risks and problems.
Trend reversal in Australia and USA
There is now a reversal of trend in Australia, where authoritative body such as Royal Australian College of GP is now advocating Doctors’ Dispensing; so is USA, where 25% and growing number of doctors are doing dispensing as the laws in most states allow it subject to approval ! We are actually trying to practice something which the world is discovering that DS is not the ideal solution for total healtcares, and rediscovering the merits of Doctors’ dispensing which we are current good at !
What are the other controversies around DS system?
There are 6 major areas that we all, as health stakeholders should be concerned about in a new untested DS system. We need to know that not all DS systems are the same. The advanced countries have overall well developed conditions which enable DS to be highly efficient and regulated. There are 8 systems as far as the writer know; basically it is divided into first world country system and the third world system.
Before we can think of implementing DS in our country, we need to know, ultimately, are the benefits more than the risks of having the system.
Here are the 6 areas of concerned:
Safety : Is pharmacy dispensing necessarily safer ?
Ideally, it is; however in practice on the ground especially in Malaysia, it is not so straightforward. Dispensing by Pharmacists must be subject to tight regulation and laws, as well as tight online monitoring, features which are extensively available in the advanced countries. We are not having this system in place. This safety advantage of Pharmacists’ dispensing is probably the sole advantage of DS, which Doctors’ Dispensing can overcome with better enhancements. Healthcare is not just about medication. It is a holistic care where doctors know everything relevant about the patient, his family and community; he also know about the laws governing cares. Dispensing is not just about giving medication according to a specific diagnosis or about giving the cheapest brand. But more importantly, about how the medication can adjust to the whole person of the patient. This is simply not available to the pharmacists. Doctors can prescribe and dispense better by being more accurate in giving the right brand and dosages in line with the total person of the patient and his conditions.
We have to realize that according to outcome studies done on the USA , errors by pharmacists in dispensing even in the inhouse institutions have fairly high rates. On the other hand, Doctors normally have a niche patient pool with whom he has become very familiar with; over time the prescription and dispensing for a limited number of patient types become highly accurate with minimal side effects. The Pharmacists have probably exaggerated the risks of doctors’ dispensing by giving anecdotal cases as highlights.
Doctors have repeatedly over time been presented with cases which have suffered either side effects of the medications, commonly of which are the highly potent steroids, or deterioration of health conditions due delayed presentation to the doctors after being treated by Pharmacists over long periods of time.
Holistic healthcares : Is Pharmacists’ Dispensing more holistic?
Pharmacists have been providng care services to the public in general. However, this would not be applicable in cases of patients cares. Malaysia has a unique endemic problem in that many, thought not all, pharmacist hold stethoscopes, examine patients and attempt to diagnose the diseases without competence; some even skip these steps to prescribe. Needless to say, this is not only illegal, it is also unethical. This has caused severely damages to the holistic healthcares by doctors.
Pharmacists’ dispensing is also not as holistic as the doctors’ primary – secondary cares clinics, because the latters is located practically any where in the country, many with 24 hour services.
DS emphasizes separation of cares where the pharmacist gain excessive amount of independence in managing patients; this is also not holistic. In our country it is not uncommon for pharmacists to dispense based on various factors, which include availability, costs, substitutes, and personal preferences independent of the doctors’ prescriptions or even consultations.
Pharmacists know more about drugs and drug to drug interactions. This does not mean doctors cannot and would not know as much about drugs. Better and longer courses on Pharmacology in the medical schools would enhance the skills on drugs prescriptions and dispensing; employing a diploma level pharmacist would put doctors on par with store pharmacists. Use of dispensing aid using technology and software would enhance the dispensing standard.
Doctors’ dispensing is also more holistic because it reduce the practical burdens of the sickly patients of having to travel to another area for medications. It is more than just being inconvenient; for a sickly person, comfort, onestop centre become a necessity. Even in the internet, we see many public forums on DS both in the developed and developing countries where grouses were heard about how troublesome it was to go to two places for treatments.
Suitability : Is Malaysia suitable for DS?
There are numerous reasons why DS is not ideal for Malaysia. The mains one are :
Firstly, the unique care culture whereby pharmacist manage patients all by himself will make DS highly risky to the health of patients. There appear to be widespread anecdotes of practices of Pharmacists throughout the country performing substandard and dangerous clinical workouts, such as taking Blood Pressure, perfoming blood tests, etc. Some retail outlets share a few pharmacists so that at times sales and cares were provided by lay counter persons. Our public culture of implicitly trusting the Pharmacists as diagnostician and primary care providers whether in the less developed states or more developed areas allow this kind of practice flourish and does not provide enough checking on the validity of Pharmacists' services. On the other hand the enforcement of laws against this anomalous situation is at best lax and inefficient, despite these laws are in place. There is simply no system of checking on the works of Pharmacists, especially an online or actual stringent check by the MOH, as such are potential high health risks to the public.
This is unlike the cases in the developed countries where the people are highly knowledgeable about their conditions and necessary treatments, and the laws are far more tightly enforced on errant Pharmacists. So, can we say our health system is ready for DS?
There is also general reluctance by the Pharmacists to make referrals to doctors for such primary duties by the pharmacists in the communities.
Other local scenarios which make DS inappropriate:
• The consequence of DS here would be that the law of the jungle would prevail among the pharmacists with the giants competing against the smaller retailers, as well as the domineering manipulation by the pharmacist over the doctors. DS before establishment of a airtight and efficient national health scheme would lead to this scenario.
• Widespread practice of having one Pharmacist running severeal outlets across districts or even states.
Commercialisation of Healthcares : Does DS lead to an unhealthy business monopoly?
We need to see the total picture of the implications of DS. Control of dispensing immediately leads to giant pharmacy chains monopolising the while market at the expense of the smaller retail pharmacists and doctors. This changes the nature of healthcare system of the country, when the holistic medical cares become beholden to the business giants whose commercial interests override the public interest. Already there are now ePharmacy in the market doing commercial promotions to sell directly to consumers and probably patients bypassing doctors clinical cares. There are also link ups with laboratory diagnostic centres which give the public a false perceptions that anyone can seek dispensing just by laboratory values without knowing that full clinical assessment and management cares by doctors are still and always will be the cornerstone of sound and safe medical cares.
Political favouritism is often linked to corporates advantages. It is not too unrealistic to see that laws of the jungle in terms of price wars and market shares may prevalil in our national healthcare. The authorities in national healthcares would possibly relinguish the healthcare standard to the vicious forces of market, unless it sets up an overarching control system to strictly prevent this from happening. However, it does not seem that the authorities would be able to do so, as it had happened to TPA/MCO having total control over the doctors fees with the authorities having virtually no power to rectify the anomalies.
DS would result in chaos in the private healthcare system in the country because 1) it causes the demise of many GPs immediately upon implementation , 2) it causes doctors to fight each other according to law of jungle because the authorities concerned refuse to promise a reasonable pricing control for the doctors and let the public know it is not concerned. Even if 1care versions come in later, no authorities would promise anything in concrete terms. In fact at worst it may suppress and total regulate our remunerations.
Readiness : Is Malaysia ready for DS?
Have the stakeholder of public consumers been thoroughly consulted on DS? This is the most critical point of note. Why is this so? Because these are the people, the patients, who are going to ultimately face the whole risks and benifits of a changed dispensing system. Difficulties arise in the implementations occur in Korea and Japan because of lack of fair and widespread consultations with the public.
In Malaysia, this had never been done in a large enough scale. The online public survey by the Pharmacy community was not earnestly done to call on the attentions of the general public but is apparently just a show of fulfilling a requirement. Hence, to determine the acceptance of DS among all patients throughout Malaysia, there is now with an ongoing nationwide unbiased survey by a neutral company appointed by the GP Community. The result will be available soonest possible.
Our Pharmacist Bill was conceived in secrecy despite these affects every major stakeholders of healthcare ie. the people and the doctors. Any open discussions are limited and not comprehensively conducted. The Bill blueprints had been forbidden from viewing by the public, doctors, and politicians except perhaps the Malaysian Pharmaceutical Society. In fact with the backdrop of secrecy we see a massive flourishing of Pharmacy chains all over the country over a short span of time suggesting their utter confidence of coming of DS.
We need to learn the hard lessons from South Korea which face doctors’ national strike during its comprehensive implementation of DS. There was lack in strategic plan for implementation. The government of Korea also fail to appreciate that the policy making paradigm of the authoritarian mean no long works. There was also lack of supporting policy infrastructure for pharmaceuticals. Furthermore there was failure to convince consumers of the benefits of the reform. Korea needs societal institutions of consensus-building on major health policy issues, which are founded on fair and transparent rules that every participant should follow. Malaysia has been practicing such secret style of governance and therefore is in danger of moving along the same ways as the Koreans.
Therefore, we are simply not ready for DS.
Doctors in Malaysia are not alone in questioning Dispensing Separation. UK and US studies
I would like to point out that the above observations are not mere irrational views. We have the support of the DDA, UK, whose surveys arrive at almost similar conclusions about supervised GPs. A number of myths perpetuate about dispensing practice. The most common are explored below
1. Conflict of interest – Myth
Dispensing practices have been prescribing and dispensing subject to the scrutiny of our local primary care organisations for years. Thanks to this external scrutiny of our NHS dispensing activities, there is ample evidence that dispensing doctors do not prescribe expensive products to make extra profits.
2. Incentives received by dispensing doctors – Myth
It is important to distinguish between (public-private) partnerships, which are allowed – even encouraged – in the NHS, and industry incentives – which are positively and proactively discouraged by all parts of the NHS supply chain.
The new code of practice for the pharmaceutical industry, published by the Association of the British Pharmaceutical Industry in 2012 specifically tackles the issue of ‘inducements to prescribe’
Excessive prescribing – either by cost or quantity – is regulated by GPs’ contractual regulations and measures are in place to deal with breaches and assure accountability to the Treasury.
Annex 8 of the revisions to the GMS Contract 2006-07 addresses ‘excessive or inappropriate prescribing: guidance for health professionals on prescribing NHS medicines’. NHSBSA data would suggest the safeguards and sanctions in place are effective in ensuring all GPs use NHS resources wisely and not for profit.
3. Doctor dispensing is more expensive for the NHS than pharmacies – Myth
Tariff pricing is the same whoever dispenses
Dispensing doctor clawback is 37.5% higher than pharmacy clawback.
The average fee per item (overall) is lower in dispensing practice. Between April and October, 2011, the spend per patient by dispensing doctors (and this includes personally administered items whilst pharmacy data does not) was £85.25 per patient; the comparable figure for pharmacy was £95.26.
4. Compared to pharmacies, there is a lack of supervision – Myth
Patient safety is assured (and prioritised) in both practice environments by the use of standard operating procedures, a robust dispensary staff training programme and the on-site presence of an accountable, registered healthcare professional to take ultimate responsibility for the safe operation of the dispensary.
There is no evidence that doctor dispensaries are any “less safe” than pharmacy dispensaries.
5. GP dispensing takes no account of population growth- Myth
Population growth and its effect on dispensing rights has been addressed since 2005 and enshrined in law in the NHS Pharmaceutical Services Regulations. The agreement between pharmacies and dispensing doctors that led to these regulations still stands and has been carried forward unchanged into the
6. Patients prefer the convenience of pharmacies – Myth
Patient choice is at the heart of the NHS – particularly its latest incarnation shaped by the Health and Social Care Act 2012. When patients are eligible to choose to receive dispensing services from their GP the overwhelming majority choose to do so. The 2008 DDA Patient Survey demonstrates patients’ preference for GP dispensing services.
7. Myth : Pharmacists will not drive up cost:
The new policy eliminated the physician incentive to prescribe unnecessary quantities of drugs and/or prescribe drugs for which they received large discounts (i.e., greater margins). Yet, the new policy did not provide physicians with incentives for prescribing drugs in a cost-effective manner and resultantly, physicians are now inclined to prescribe high quality, expensive drugs. This, in effect, substantially increased the market share of global pharmaceutical manufacturers. The principle of brand name (rather than generic) prescription by physicians exacerbated that tendency.
Impact of this policy : The impact of the reform will not be as fundamental as originally expected because a vested interest group succeeded in distorting the content of the policy for their own interest. Due to the increased prescription of high quality, expensive drugs, impact on cost efficiency is not as high as originally expected.
What we think is best for the healthcare of the country.
We have arguably among the top 5 best primary healthcare system in the world. Break this system and trying out an unpredictable and complex system, we may never have the chance to get back to that best system.
The DS issues had been hotly discussed among many General Practitioners’ in Malaysia, specifically, MMA, MPCAM, PERDIM, GPUnited Malaysia, and others.
We believe that the way to move forward is to strengthen the excellent existing Primary Care system, together with equipping the doctors with best dispensing skills and systems including employing of Pharmacist and use of digital technology for this purpose to fulfill the role of diagnostician and dispensing in our local niches, just as well as Pharmacists can do.
In an untested and complex system of Dispensing Separation in the context of community healthcare service, especially with the current state of Pharmacists in our communites across the country performing dubious and highly risky managements of patients on their own, we are indeed courting severe damages to our excellent healthcare system which is not without remedial faults.
Who are against DS
1. Malaysian Consumer Association
2. Muslim Consumer Association
3. Malaysia Consumer Movement
4. General Practitioners Groups.
PERDIM (Datuk Dr. Ahmad Shukri Bin Ismail), MCPAM (Dr Jim Loi)
(Team of Writers : Dr Low Boon Teck, Dr Mohd Hanifah Hamidon, Dr Raj Kumar Maharajah, Dr Mior Yusof, Dr Aman Shah, Dr Raja Kohlia, Dr Thirunavukarasu Rajoo)