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System of dispensing medicines by doctors working well

By Dr Shanmuganathan T V Ganeson
May 31, 2016

I refer to the recent opposition by pharmacists to the decision of the Ministry of Health (MOH), based on feedback on the proposed Pharmacy Act (Bill), and their interest in garnering public opinion to oppose the Bill through an online petition.

I would like to narrate the events prior to the May 9 decision for readers to view the issue in perspective.

For many years, pharmacists were directly involved in drafting the Bill through the Pharmaceutical Services Division (PSD), with input from the pharmaceutical industry representatives.

The Bill was an omnibus bill that sought to amalgamate four existing Acts regulating medical practice in Malaysia.

In March 2015, the medical practitioners were invited for a "Briefing Session on the RUUF" by PSD. (RUUF stands for "Rang Undang-Undang Farmasi" or Pharmacy Bill)

By then, rumours of industry-manipulated changes in the draft Bill were circulating among medical practitioners, raising grave concerns.

At the March 2015 meeting, fearing intrusions by the Bill into the existing Acts governing medical practice, the doctors demanded to see a copy.

When the Public Service Department (PSD) chairperson could not accede to the request for the Bill to be shown, the doctors requested that they be excused from the meeting and that it be minuted as such.

They refused to be named as participants in a process devoid of their input. The meeting was then abruptly adjourned.

The doctors felt that the Bill should confine itself to pharmacy and matters related thereto and not regulate or infringe upon the practice of another profession, more so without any consultation.

It is noteworthy that the online public engagement on the Bill by the PSD held earlier, as part of the requirements before tabling of that Bill in Parliament, was clearly a sham as the respondents comprised of 95% pharmacy industry-related respondents, rather than the public.

These all spoke of the many deficiencies in the drafting of this Bill.

It is undeniable that the medical practitioners' fears on the unseen Bill were valid.
MOH then organised a stakeholders' meeting in December 2015, moderated by Pemandu (the Performance Management & Delivery Unit, based in the Prime Minister's Department).

It was a week-long meeting, where nearly 100 pharmaceutical industry representatives were invited, as opposed to less than 10 medical, dental and veterinary practitioners.

At the stakeholders' meeting, the doctors defended the issue of mandatory prescription, citing:

A. Problems of Prescription Abuse and Diversion:

1. In 2010, 38,000 people died of overdoses in USA. Of these, 22,134 were caused by overdose involving prescription drugs. Three-quarters involved opioid pain relievers.

2. Fraud in prescriptions: Legitimate prescription pads stolen from clinics, alteration of prescriptions by patients, copying of legitimate prescriptions and subsequent abuse of these.

B. Panel patients (cashless) did not need prescriptions as supply of medicines was pre-arranged in the contracts between third-party payers and TPAs (Third Party Administrators, managing the health benefits of employees).

C. Prescriptions are written in patient cards and registration books as required under the existing Acts. Prescriptions are given on request of patients, rendering the need to mandate this needless.

D. It was ridiculous to write out a prescription when the same will be filled out within the walls of the clinic, unlike in hospitals where the pharmacy was located elsewhere.

The doctors also presented the Joint RUUF Memorandum of April 2015, signed by the medical, dental and veterinary associations, and which was submitted to the MOH. The memorandum stated the following:

1. The present system of dispensing of medicines by doctors was an accepted practice in Malaysia. This was also true of developed nations like Singapore, Hong Kong (SAR), parts of the USA, Australia and UK.

2. Malaysia's existing system was a proven integrated system of care that is cost saving, convenient one-stop service, patient-centric and preferred by the public. Dispensing Separation (DS) would disrupt a well-proven system of a one-stop GP-dispensing system that had evolved over the last 50 years in a Malaysian way. To date, the opponents of this existing system had not produced any proper studies indicating the ill-effects or negative aspects of this system in Malaysia.

3. On top of this, the proposal for separation of prescription and dispensing was not supported by any evidence-based studies whatsoever.

4. Furthermore, there had also been no proper research studies on the issue of doctors dispensing medicine in relation to developments and innovations in the pharmaceutical industry, which had made dispensing non-technical. The practices of dispensing had been made simpler and less technical by the pharmaceutical industry with the production of pre-packed medicine and ready-to-use mixtures – negating the need for apothecary. Dispensing was thus easily achieved in a physician-based practice.

5. Issues that arose in support of DS, such as over-treatment and poly-pharmacy, occurs in both systems, regardless of whether doctors dispense or otherwise.

6. The Poisons Act 1952 and its regulations permit dispensing by doctors and also by paramedics working in government health centres and private sector, 1Malaysia Clinics and estate hospitals.

8. The National Drug Policy (Dunas) 2012 endorsed the dispensing of medicines by doctors with the definition of dispensing as per the Poison's Act 1952 and also the relevant provision in the PHFSA 1998 & its Regulations (2006).

9. Countries where dispensing is separate usually have a third party payment system – such as social health insurance. Even in Singapore, where there is a health financing system, dispensing by general practitioners continues to be permitted. In Malaysia, private healthcare service is fee-for-service, paid out-of-pocket by patient or by private funds. Thus patient's preference is paramount.

10. The consequences of separation will result in fragmentation of care, liability issues, increase in cost (South Korean example) and inconvenience to our patients. Those who have experienced absurd inconvenience in other countries, wherein there is dispensing separation like New Zealand or UK, would oppose such a move here. The situation in rural areas under-served by pharmacies makes DS untenable.

Contrary to the current online petitioners' perception, the May 9 decisions by the MOH were not of a doctor-minister favouring his fellow doctors, or a doctor-director-general of health being uncaring to members of their sister professions.

MOH has to contend with the Bill which seeks to intrude into existing regulations, into regulations of other professions and which did not take heed of impact of changes to delicate patient care and potential for disruption of accepted norms of Malaysian healthcare.

While the doctors were pleasantly surprised by the temporary reprieve, they did take note of the DG's reminder that many of the proposals forwarded by the pharmaceutical lobby could only be implemented once a system change of healthcare financing is in place.

Dr Shanmuganathan T V Ganeson is the honorary secretary of the Federation of Private Medical Practitioners’ Associations of Malaysia (FPMPAM).

Originally published in freemalaysiatoday.com
http://www.freemalaysiatoday.com/category/opinion/2016/05/31/system-of-dispensing-medicines-by-doctors-working-well/

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