Being one of the representatives of pharmacists in the Committee, William Chun-Ming Chui, President of the Society of Hospital Pharmacists, sat down with MIMS to openly discuss the difficult situation pharmacists are now facing, and what can be done to improve.
Separation of medical care and drug prescribingThe pharmacist surplus has sparked positive discussion on the reasons behind the phenomenon on our online community in January, with some pointed out the lack of a separation of prescribing and dispensing in Hong Kong as the root cause.
Chui echoed with the community users that the separation of prescribing and dispensing is a global trend. “While we cannot claim ourselves doctors, ironically doctors can dispense medications without appropriate pharmacy training. Almost all Western countries have this separation in place. Our Asian neighbours, such as Japan, Korea and Shenzhen in China, also want to implement such separation,” said Chui.
While some have accused pharmacists of driving this separation because they want to capture the profit from selling drugs, Chui claimed this is not the case as such separation tends to be driven by health insurance companies.
“Health insurance companies need to ensure a separation is in place in order to prevent doctors from abusing the insurance claims, including prescribing unnecessary medications. Without such separation, and if there is no one to verify whether the claim is genuine, the overall healthcare cost will increase, jeopardizing the entire claims system,” he explained. “Also, instead of judging which medication is more suitable to the patients, doctors might decide which drug to prescribe based on the bonus terms and discounts provided by the pharmaceutical companies. This would affect the treatment quality or even do harm to the patients,” he added.
PPP: Bringing quality pharmaceutical care to the community levelAlthough there is no separation of prescribing and dispensing at the community level, at public hospitals such separation has basically been achieved.
“Currently, pharmacists at public hospitals verify doctors’ prescriptions and supervise technicians to dispense. There is a separation since the drugs are issued by us rather than by the doctors,” Chui pointed out.
“However, our role as pharmacists is not fully utilized. Due to insufficient manpower and the need to handle more than 2,000 prescriptions a day at specialist outpatient departments, it’s impossible for us to review patients’ drug profiles or handle their drug-related problems,” he admitted.
According to Chui, this is where the PPP comes in — to outsource parts of the dispensing duties for stable patients with selected chronic diseases to community pharmacists.
“Firstly, by reducing the total number of patients at public hospitals who use our pharmaceutical service, we can shorten patients’ waiting time in collecting medications. Secondly, patients with chronic disease managed at public hospitals can rely on designated community pharmacies or dispensing centres for professional follow-up instead of waiting for a long time for the next return visit. With this in place, we will be able to prescribe a shorter course of treatment each time, thereby reducing drug waste and the risks of patients becoming confused about the dosages and directions of use of various medications,” suggested Chui. “Yet, what’s more important is that this empowers the community pharmacists. This enables them to take care of the patients and tackle drug-related problems.”
Phase one: 10 per cent of Hospital Authority’s chronic disease patientsWith high hopes of such partnership to alleviate the workload of the public sector, Chui claimed the pilot program of the partnership aims to refer 10 per cent of chronic disease patients from public hospitals to community pharmacists.
“These patients are the elderly who are staying in old age homes. Most of the time it’s the care assistants from the old age home who come to the hospital to pick up the medications. In this case, it is difficult for us to deliver the right message to the elderly. This is the reason why we want to outsource this group of patients to the community pharmacists so that they can visit the elderly home and review their medication profiles directly. This includes resolving their drug related problems, such as reducing unnecessary drugs and side effects due to polypharmacy issue,” Chui explained.
A prerequisite for success of PPPAsked if the government is supportive of implementing the PPP, Chui’s answer was positive. However, he noted that success of the initiative requires pharmacist professionals, including hospital and community pharmacists and the two pharmacy schools in Hong Kong, to propose a feasible model. “We do hope the government will take the lead to set up a working group for PPP. The discussion would be efficient if the government leads us to the right direction,” said Chui.
Currently, it is mandatory that pharmacists are available at community pharmacies for at least ⅔ of the opening time. While most pharmacists are stationed at community pharmacies during daytime, Chui commented that many patients visit the pharmacies at night when the pharmacists are off duty.
“When patients cannot find the pharmacists inside the store, they would reach out to the shopkeepers for help. It is very likely that patients would rely on these shopkeepers, who do not have any relevant professional training, to recommend medications for their use. As time goes on, patients will no longer bother to ask the pharmacists about drug-related issues, and these shopkeepers will replace our role,” he said. “In the end, public safety and health will be adversely affected.”
Consequently, full coverage with pharmacists stationing at community pharmacies all the time will become a prerequisite for PPP. “Since we expect there will be an increase in doctors’ prescriptions from public hospitals due to the PPP, we need to ensure there are sufficient pharmacists to take care of patients in the community pharmacies,” he said.
However, Chui understands some community pharmacists are afraid of extending the working hours without a pay increase. Some pharmacists also expressed concerns that community pharmacies may recruit part-time pharmacists to support the extended hours, while the cost of hiring the part-time pharmacists would be deducted from the full-time community pharmacists.
Chui proposed two initiatives to prevent this from happening. “First, we can start with non-profit pharmacies established by non-governmental organizations (NGOs). Second, we can encourage groups of pharmacists to form together a dispensing centre. The owner of this centre has to be a pharmacist, who is not solely oriented towards profit,” he said.
Chui foresees some community pharmacies may oppose such initiatives since this seems to benefit only a small number of pharmacies. “If other community pharmacies want to join PPP, then they will have to fulfill some sort of requirements and criteria, such as whether the business owner would interfere with the professional judgement, coverage of the service, policies to protect patients’ privacy,” he listed. “I do not prefer all community pharmacies joining the program when this is launched. We have to uphold the quality and standard of our pharmaceutical services,” he emphasised.
Maximizing the role of pharmacists in public hospitalsApart from the PPP, Chui is grateful the government is highlighting the importance of pharmacists in the Policy Address 2017. According to the paper, the government will “strengthen and make better use of the pharmacist manpower of the Hospital Authority (HA) to expand clinical pharmacy services and enhance drug reconciliation, consultation, checking and management services for patients in order to promote proper drug consumption and reduce drug wastage.”
As the shortage of doctors will persist even after 10 years, Chui suggests that the government can utilize the roles of other healthcare professionals. “Pharmacists, in particular, have a close background with doctors in terms of our training, knowledge and clinical practice. Although we cannot perform diagnosis, we are equipped with the knowledge of the diseases. For example, if a patient comes to you and says he feels dizzy after taking some medications, how will it be possible for you to distinguish whether it is because of the illness or the medications if you do not have the necessary knowledge?” he described.
While clinical pharmacists often discuss the best drug treatment options with doctors, community pharmacists can also contribute more. “At the point of admission to hospitals, doctors need to review patients’ drug profiles. At the point of discharge, doctors need to determine whether they should prescribe other medications to the patients or whether the patients should continue taking their current drugs. These are the times when we can assist doctors in medication review,” said Chui.
Chui quoted findings from one of the public hospitals, where at least 60 cases of near-miss by doctors were picked up by pharmacists throughout a day with an attendance of more than 2,000 patients at specialist outpatient clinics.
“To err is human. We are not blaming doctors for making mistakes. However, by easing doctors’ workload, they can allocate more time to patients’ treatment, thereby enhancing the quality of overall patient care. This is a win-win-win situation for doctors, pharmacists and patients,” said Chui.
Future development of pharmacists in HK: Creating a win-win-win situationConcerning a comment made by some pharmacists to shut down the two pharmacy schools in Hong Kong in case of existing pharmacy surplus, Chui commented one should look at the long-term development, including the impact made by PPP in the future and other government initiatives. Instead of shutting the schools, Chui said it is more appropriate to consider adjusting the number of intakes. However, Chui emphasised such decision should only be made once consensus is reached by all parties.
On closing the surplus gap, Chui looks very confident. “Upholding the quality of healthcare is not a solo practice, but a multidisciplinary collaboration. Indeed, all hospital wards in the future should have doctors, nurses and pharmacists on duty, since different professions have different specializations. Apart from the PPP and other government initiatives, factors such as the growing development of primary care and an ageing population are also opportunities to utilize the role of pharmacists. The demand for pharmacists is growing. Therefore, I am optimistic on the outlook of pharmacist development in Hong Kong,” he said. MIMS
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