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PSHK Healthcare Reform Position Paper—August 1999
THE PHARMACEUTICAL SOCIETY OF HONG KONG
___________________________________________________________________________
Health Care Reform in Hong Kong : The Role of
the Pharmacy Profession
Positions and Recommendations in Response to the
Harvard Health Care Reform Report
August 1999
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PSHK Healthcare Reform Position Paper—August 1999
Contents
Page
1. Introduction
3
2. The vision of the pharmacy profession
4
2.1
The benefits of a health care system with separation of
6
dispensing and prescribing
3. Provision of pharmaceutical care and clinical pharmacy
7
4. Community pharmacy service
8
4.1
Self-care: increase of pharmacy-only-medicine
4.2
Development and support of the concept of family
8
10
physician stream
4.3
As educators
11
4.4
As an interface between private and public sectors
12
4.5
Increase ownership of pharmacies
13
4.6
Reduction of polypharmacy
13
4.7
Follow up of patients' prescription
14
4.8
Other services
15
5. Hospital pharmacy services
15
5.1
More effective cost control
15
5.2
Aseptic dispensing
17
5.3
Control of antibiotics
19
5.4
Drug information service
20
5.5
Other clinical pharmacy services
21
6. Setting up of a monitoring system
21
7. Complaints channel
22
8. Conclusion
23
Appendix I
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PSHK Healthcare Reform Position Paper—August 1999
1. Introduction
Pharmacists have long been highly regarded in many countries. In Gallup polls in North
America, the pharmacy profession has always been ranked as one of the top amongst all other
professions. It is also considered as highly ethical, only next to Clergyman in the society.
Patients trust their pharmacists and appreciate their service and help. The Pharmaceutical
Society of Hong Kong, with its 50 years of history, and representing the pharmacy profession
from various practice, has long recognised that the potential of pharmacists cannot be fully
utilized under the present system. There has been insufficient participation of pharmacist in
important matters pertinent to health care and there is not enough understanding and respect
for the profession. It was not until 1992 that there was a milestone in the history of pharmacy
in Hong Kong. It was in that year that the pharmacy school at the Chinese University of Hong
Kong was set up.
With the recent release of the Harvard Report, the pharmacy profession feels that there is an
imminent need for our profession to address our concerns related to pharmaceutical services.
We advocate a health care system whereby there is true separation of dispensing and
prescribing, as in the more advanced countries including the United States, the United
Kingdom, Canada and Australia, etc. In our neighbouring countries, such as Taiwan, this
separation has also taken place and time is seeing the benefits from the perspective of the
patient, as well as the health care provider. It can be seen that the separation of dispensing and
prescribing can bring very positive health benefits. The proposed separation does necessitate
an insightful investigation. The benefits brought about are diversified and it is our purpose to
expound these advantages in this report. In the following sections we will examine the role of
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PSHK Healthcare Reform Position Paper—August 1999
pharmacists in addressing the objectives of the reform as stated in the Executive Summary of
the Harvard Consultancy Report, as follows:
(1) maintaining and improving equity
(2) improving quality and efficiency
(3) improving financial sustainability by managing the government budget on health by better
targeting of government subsidies
(4) meeting the future needs of the population
(5) managing the overall health expenditure inflation (1)
2. The Vision of the Pharmacy Profession
Rather than asking for an immediate complete separation of dispensing and prescribing, it is
imperative that to first nurture an environment deemed to be appropriate for this to occur. The
current system does not provide the right infra-structure and conditions to carry out a total
separation of dispensing and prescribing. This would be too drastic to be carried out at this
stage. We think that it is more essential to endorse this complete separation of dispensing and
prescribing system in the SAR Government's policy on Hong Kong Health Care System, thus
paving a way for the future separation.
More work on the role of pharmacists should be implemented. The public ought to know
what kind of work a pharmacist does. Pharmacists should be consulted on important health
care decision making. The pharmacy profession definitely wants to see more of the notion of
“collaborative care” as seen in the other countries where doctors, nurses, other health care
providers and pharmacists all work hand in hand. (2) The professional role ought to be
enhanced.
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PSHK Healthcare Reform Position Paper—August 1999
At present, there are not enough pharmacists. According to the recent Chinese University
Press Conference, the pharmacist to patient ratio is 1: 20,000 versus 1: 5000 in the United
Kingdom. (3) Fortunately this does not pose a great barrier to the profession as we have
replenishment of workforce from the local university as well as the return of overseas
graduates. However, it is crucial that in order to let the pharmacist fully function as a drug
specialist and expert, manpower should not be underestimated. To go fully in line with what
we are about to suggest, more pharmacists are definitely needed whether they are working for
the hospital, community, industry or the Government.
Besides the enhancement of professional role, the pharmacy profession thinks that
pharmacists can help answer some of the criticisms arising from the Harvard Consultancy
Report:
(1) Overcharging of doctors: many doctors are currently not listing out the prices of drugs,
conferring a confusion upon the patients as to how much money is spent on medications
and consultation;
(2) Abuse of antibiotics: there are currently increased incidences of abuse in this kind of
drugs making the resistance of bacteria a gradual threat to the general public. There are
also incidents where doctors prescribe a non-effective three-day course of antibiotics. This
reflect the issue of conflict of interests for sheer money making without considering the
risk to the patient as well as to the community;
(3) Lack of patient education: many patients rely too heavily on medical doctors as they are
in a great lack of general health knowledge. This phenomenon is not common in other
industrialized countries where dispensing is separated from prescribing as general public
are more informed on general health issues;
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PSHK Healthcare Reform Position Paper—August 1999
(4) Inadequate checks and balances among the professions and patients finds it difficult to
challenge the doctors because of a lack of open and equivocal complaint channel.
Other problems that are encountered in the current Hong Kong health care system are similar
to those in the rest of the world: (a) increasing age of patients (b) increasing expectation and
knowledge of patients (c) increasing cost of drugs and medical facilities (d) capped allocation
of funds from the government.
It must be emphasized that we are not going to solely focus on the question of money. It is
our belief that reform in financing goes hand in hand with the reform in the re-structuring of
health care including the re-evaluation of the pharmacists’ role. Spending on health care
service needs to be prudent and cost effective during the current time of recession. Moreover,
the suggestions we put forth are to prepare the health service to cater for the final system of
separation of dispensing and prescribing. They also go in line with “those who can pay shall
pay for themselves” as health care expenditures are ever rising.
2.1 The benefits of a health care system with complete separation of dispensing and
prescribing
To set the scene, some summary points are presented here:
2.1.1 What is undesirable in the current doctor-dispensing system?
1. Dominance of medical doctors
2. Lack of patient counselling leading to various problems such as non-compliance, adverse
drug reactions, etc.
3. Conflict of interests
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PSHK Healthcare Reform Position Paper—August 1999
4. Lack of transparency
5. Lack of competition
6. Barrier to self-care resulting in overly burdened hospital service
2.1.2 Benefits of separation of prescribing and dispensing
1. Doctors prescribe the most suitable medication to the patient without considering any
special terms with the pharmaceutical companies or the stock situation within the little
dispensary in the clinic
2. Transparency of charges for each of the medication
3. Participation of all health care providers with no over-relying on one particular profession
4. Increase of market force leading to more competitive drug costs
5. Patients can become more knowledgeable on drugs
6. Increase of the awareness of self-care: patients will not just rely on curative but also on
preventive measures (please refer to Appendix I, "The role of the pharmacist in self-care
and self-medication" from World Health Organisation)
3. Provision of Pharmaceutical Care and Clinical Pharmacy
Pharmacists play a great role in the delivery of pharmaceutical care. It is a practice in which a
pharmacist takes responsibility for a patient’s drug-related needs, and is held responsible for
his commitment. This is delivered when an assessment is performed, a care plan being
developed and a follow-up evaluation is completed for a patient. (4) In addition, clinical
pharmacy entails a health science specialty which embodies the application by pharmacists of
the scientific principles of pharmacology, toxicology, pharmacokinetics, and therapeutics to
the care of patients. On one hand, the professional role of pharmacist is enhanced through the
practice of these concepts; and on the other hand, these concepts can help crystallize the
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PSHK Healthcare Reform Position Paper—August 1999
success of expenditure minimization. This will be further exemplified in the ensuing
paragraphs. It must be emphasized that it is our belief that these concepts can help bring the
general public health benefits as far as medications are concerned. And more importantly,
reduction in expenditure of drugs can be achieved.
4. Community Pharmacy Service
This is an important sector in Hong Kong as most community pharmacists are readily
accessible. However, it is alarming to know that community pharmacists have been under
utilized. The role of community pharmacists should not be neglected.
4.1 Self care: increase of pharmacy-only-medicine
Community pharmacists can be the frontier in self-care. In this setting, they can participate
widely and actively in primary health care as pharmacists can be easily accessible. Most of
the community pharmacies are in close proximity to residential areas. They can shoulder
some of the burden borne by the Accident and Emergency Departments (A & E) of hospitals.
Fewer patients will then go to A & E for the services as they can seek help readily from the
community pharmacists.
Nowadays, for trivial diseases, patients often opt for the A & E services. It seems that in
patients’ perspective, public health care services are only obtainable via hospital-based
means. There are inadequate alternatives for those who do not necessarily need in-patient
treatment. Not only is this ineffective in serving the patients’ needs, but it also drives up the
costs of health care. There are therefore heavy costs for employees, employers and the
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PSHK Healthcare Reform Position Paper—August 1999
community as a whole if hospitalization is the only available option because out-patient
facilities are insufficient and underdeveloped. Primary health care should be better developed.
Facts to support increase of Pharmacy Only Medicines (Ps) can be found in Denmark.
Programs to increase the number of Ps started in 1989. There was a deregulation of 81
products with the aim of saving £90 million. As a result, overall expenditure was being cut
down successfully. There were no reports of increased incidence of adverse reactions. In
addition, in the United States, a thorough review of OTC products available in the market
began in 1972. Pharmacists act as drug advisers on minor ailments such as stomach-ache,
motion sickness, or cold etc. (5)
The inclusion of more Ps implies a greater input to primary health care by both community
pharmacists and the public themselves. This is in echo with the report which criticized that
there is too much money spent in the hospital sector. “Hospitals are dominant institutions
providing health care in Hong Kong. Priority is given to hospital-based services. (1)
Hopefully, there is a healthier balance between the two settings. Moreover, with the practice
of a good “self-medication” practice being encouraged, medical doctors will not be seen by
the public as the sole source of drug advice or the exclusive controller of assess to medicines.
The role of pharmacists, in the discipline of “milder ailments” or “self-curable ailments”, will
become a collaborator with patients to work out the management of health problems.
Patients’ choice are as a result diversified.
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PSHK Healthcare Reform Position Paper—August 1999
4.2 Development and support of the concept of family physician stream
Hong Kong faces increasing socio-health problems that are typical of post-industrialized
countries such as mental disorders, alcoholism, sexually-transmitted diseases and substance
abuse. With a life expectancy of 79 years, Hong Kong residents are also increasingly under
the threat of chronic diseases such as diabetes, heart diseases, stroke and cancer. Japan, Great
Britain and the United States have recognized that the compartmentalized services cannot
effectively address to these afflictions that plaques the countries, i.e. these socio-health
problems and chronic illnesses.
About 50 years ago, the U.K. developed the system of family physicians to manage the health
care needs of a population living in a post-industrialized era and began its development of the
GP system. (1). In a system where family physicians work hand in hand with community
pharmacists, prescriptions released from the family physicians can be checked by
pharmacists. Thorough patient counselling can be given to the patients. Drug therapy
problems can be identified which consists of:
(1) Need for additional therapy;
(2) Unnecessary drug therapy;
(3) Wrong drug;
(4) Dosage too low or too high;
(5) Adverse drug reaction;
(6) Compliance.
We know that these problems are not uncommon happening among patients in Hong Kong. A
recent patient survey conducted by the Pharmacy Department of the Queen Mary Hospital
fully supports this aspect, both in the community and in the hospital settings (6). With
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PSHK Healthcare Reform Position Paper—August 1999
intervention from pharmacists, the rate of occurrence should definitely be much reduced.
Moreover, it should be noted that all other health care providers such as Chinese medical
practitioners, nurses, dietitians, occupational therapists, physiotherapists, optometrists, speech
therapists and podiatrists should also be included. There should not be one profession being
particularly being over dominant in the health care system.
4.3 As educators
Pharmacists can help in the education of the public on drugs themselves during counselling
and perform health promotion to the public especially in the community settings. Issues that
will be touched upon include:
1.
possible side effects;
2.
ways of avoidance of these side effects;
3.
how to optimize compliance on drugs;
4.
modification of lifestyle to combine with drug treatment;
5.
prepare pharmaceutical plan;
6.
promote healthy lifestyle and preventive measures;
7.
enhance communication between health care providers and the public.
A lot of drug wastage is caused by side effects. Patients just resort to discontinuation of
taking the drugs instead of reporting these back to the doctors, reflecting a lack of education.
Other possible education topics include:
1.
immunization
2.
family planning
3.
various screening tests
4.
chronic disease management
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PSHK Healthcare Reform Position Paper—August 1999
5.
maternal and children health care
6.
drug and alcohol abuse prevention
During the process, help can be solicited from the Education Department and the
Environmental Protection Department in creating public education sessions. A similar idea
has been given in the Report, i.e. the set up of the patient education office by the Department
of Health. Pharmacists should be part of it, be invited to participate and to co-organize such
events.
In terms of connection with citizens living within a particular area or district, community
pharmacists play a crucial role since they can help out in the delivery of health seminars. They
can also link up with nursing home, care and attention centres and old aged homes. Very
often, people living in these institutions have problems with their medications because of low
education, lack of instructions from doctors and lack of supervision of the carers. Pharmacists
as educators of drugs can therefore help strengthen these areas.
4.4 As an interface between private and public sectors
In the report, the health care system of Hong Kong has been criticized to be the one which is
highly compartmentalized. Pharmacists are in an appropriate position to take care of the
bridging between the hospital and the community. As one might already be aware of, there is
the redistribution of prescriptions from public hospitals to the community setting such as the
dispensing of sildenafil tablets. And in the coming year, it is expected to include more
categories of drugs.
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PSHK Healthcare Reform Position Paper—August 1999
As health expenditure is increasing day in and day out, pharmacists can act as an interface
between the hospital and community settings. Studies overseas have shown that pharmacists
are the most accessible health care professional to many chronically ill patients. For example,
pharmacists see diabetes patients five times more often than any other health care providers.
Besides this high accessibility which proves to be crucial for pharmacists taking the
medication aspect of discharged patients from hospitals, pharmacists also have a strong focus
on counselling, health education, and interaction with patients. These virtues have also made
pharmacist the ideal candidate to be a bridge between the public and private health care so
that a so-called seamless health care environment can be achieved.
4.5 Increase ownership of pharmacies
The idea of having a pharmacist as a partner or the sole owner of a pharmacy is to be
advocated. The main difficulty sometimes lies in the fact that pharmacists might not have the
necessary capital to start with. It is hoped that the Government can support this start off with
some sort of business loans to support the idea. This is advantageous to the health care field
as that implies more control to the pharmacy services a drugstore could possibly provide and
the “code of ethics” can be in better mastery.
4.6 Reduction of polypharmacy
Polypharmacy has been defined as the use of multiple prescriptions and OTC medications
especially by the elderly and patients with chronic health problems. The practice of
polypharmacy has led to the increase in risk of adverse drug reactions such as drug-drug,
drug-food and drug-disease interactions. Besides, non-compliance is also found to be a
problem.
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PSHK Healthcare Reform Position Paper—August 1999
Patients can be educated to keep a profile of their own and can be reviewed when drugs are
dispensed or such profile can be kept by the community pharmacists if the patient agrees.
Unnecessary medications can be questioned/eliminated and as a result, the drug regimen can
be simplified. The measures adopted in the minimization of polypharmacy aims at decreasing
expenditure on drugs as well as improving compliance The main steps involved are:
1) have the right drug for the right reason: the clinical indication for each medication should
be identified. Medications with no clear indications, no clear benefits or inappropriate
medications are questioned;
2) consider if a drug is needed: non-drug measures need to be considered. For example,
patients with gastrointestinal reflux should be advised and educated about proper nondrug measures for anti-reflux;
3) use a single agent if possible to treat several diseases – if possible, choose a single drug
that can alleviate several problems;
4) choose drugs with a once or twice daily dosage regimen – this kind of dosage is
associated with the highest compliance. Drugs with the long half lives should be chosen
whenever suitable. Alternatively, extended release preparations can be chosen. (7)
4.7 Follow up of the patients’ prescription
In British Columbia, Canada, a program called “trial-prescription” program has been
successfully carried out and what it aims at is to cut down drug wastage and the overall cost
paid by the patient. With agreement with the prescriber after consultation on the programme,
a patient who joined the programme would be assigned to go to a particular community
pharmacy. The pharmacist would dispense a small quantity, like a week’s worth of supply
instead of the whole month supply prescribed by the doctor. The pharmacist would also
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PSHK Healthcare Reform Position Paper—August 1999
follow up by contacting the patients by phone to see if the drug is effective or if there were
any undesirable side effects. In about 35% to 45 % of the case, the patients had chosen not to
fill the remainder of the one-month supply. Similar services can be carried out in Hong Kong
and should be conducive. (8)
4.8 Other services
The community pharmacy can really provide a myriad of services beside the ones mentioned
above. Various campaigns can be hosted in the community pharmacy, such as DUMP
(Disposal of Unwanted Medicines and Poisons) campaign which can reduce the availability
of unneeded medicines at homes, so reducing inappropriate use of drugs and incidents of
accidental poisoning. Similarly, sun-awareness and smoke cessation campaigns help reduce
skin cancer and respiratory cancers respectively. These are all examples to illustrate that
pharmacists as drug experts can function in a variety of roles in the pharmaceutical,
environmental and educational perspectives. (9)
5. Hospital Pharmacy Services
Hospitals in Hong Kong have adopted the separation of dispensing and prescribing system
and the introduction of innovative programs have been given applause by many health care
professionals. Overall speaking, it has been successful though there is still a lot of room
where there can be further enhancement of the role of pharmacists.
5.1 More effective cost control
Pharmacists are not only drug experts, they can also advise on the appropriate drugs of choice
according to the budgetary needs of the hospital administrators or others who are concerned
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PSHK Healthcare Reform Position Paper—August 1999
about “money”. Pharmacists do have a role in acceptance or rejection of drug usage in
hospitals. Their participation in compiling the formulary is well respected both in Hong Kong
and overseas.
A formulary as defined by the American Society of Hospital Pharmacists as a “method
whereby the medical staff of an institution, working through the pharmacy and therapeutics
committee, evaluates, appraises and selects from the numerous drug entities and drug
products that are considered as most useful in patient care.(10) Only those so selected are
routinely available from the pharmacy.” A formulary is therefore an important tool in assuring
the quality of drug use and controlling its cost. A well- managed formulary has three
advantages:
(1) help ensure the quality and appropriateness of drug use within the institution
(2) teach appropriate drug therapy to the staff
(3) provide information on the cost-effectiveness of drugs, not just simply drug reductions
HK$970 million was spent on drugs among the health care expenditure in 1995-1996. And in
1997, this further rose to over 1 billion. There are various measures taking place within the
Hospital Authority that has proven to be effective, for example the Drugs Utilization
Committee & Drugs and Therapeutics Committee. Besides actively being involved in these
committees, pharmacists can demonstrate their expertise in bulk drug purchasing and
tendering for hospitals.
There are several reasons for having pharmacists’ participation. New drugs are constantly
becoming available and pharmacists can help in the assessment of the quality, safety, efficacy
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PSHK Healthcare Reform Position Paper—August 1999
and cost-effectiveness of these new drugs in treating patients. A Drug Utilization Review
Committee (DURC) is composed of experts from specialty clinicians, pharmacists and
academic physicians. They review the usage of drugs in public hospitals. Pharmacists support
the Committee by evaluating, analyzing and disseminating information on drugs based on
published literature and other documented studies. This Committee also issues guidelines on
quality cost-effective prescribing practices, and organizes cost-effective drug therapy
educational workshops for clinicians. Similar in both the community setting or the hospital
setting, health care professionals including doctors and pharmacists are encouraged to
communicate with patients about the use and effectiveness of drugs.
Presently, many public hospitals have their own Drug and Therapeutics Committee (DTC)
made up of clinicians, managers and pharmacists. They use the DURC guide as a tool to
develop their own prescribing guidelines, which are constantly reviewed in the light of
changing technology. (11) However, should resources in pharmaceutical care be more
sufficient, the participation of pharmacists in drug budget management and in the selection of
most cost-effective therapy can be further enhanced.
5.2 Aseptic dispensing
The preparation of aseptic products has been long been regarded as a value-added service
provided by pharmacists. Hospital pharmacists have been involved with the preparation of
parenteral dosage forms for several decades in countries like the US, Australia and Canada,
etc. Preparations involve TPN (Total Parenteral Nutrition), cytotoxics (chemotherapeutic
agents), CIVAS (Centralised Intravenous Addictive Services) and sterile eye products. These
preparations are common. The word “parenteral” basically means outside the intestine and
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PSHK Healthcare Reform Position Paper—August 1999
they are administered by injection into the veins or through subcutaneous muscles. The
pharmacy provides a safe, clean environment with laminar flow-hood in place for centralizing
the preparation and proper record-keeping. The pharmacist checks before and after
preparations reconstitution against the patients’ profile, making sure that there is no drug
interactions and the dose is appropriate. Moreover, pharmacists with the expert knowledge on
drugs perform medication calculations, which are extremely crucial in parenteral therapy
dosages. It has been shown that pharmacists are less likely to make errors in calculation in
relation to the volume of each ingredients added if compared with other professionals.(10)
Pharmacists also make sure that the prepared parenteral admixtures are free of contaminants
and each component is compatible with each other.
In terms of cost, pharmacy can provide parenteral medications more economically than
individual nurses on a patient unit. The overall cost of drug and diluent procurement, storage,
preparation time, and waste is less in a pharmacy-based admixture program. Intravenous
programs that are under the direction of nursing staff require coordination effort to obtain
drugs from pharmacy as well as diluent solutions. Since the preparations are prepared in bulks
like the ophthalmics, labour and waste are decreased. Nursing time associated with
preparation of medications for administration to patients is minimized. It is then possible to
translate the reduction in time into either an actual cost saving to the hospital or to provide the
nursing staff more time in actual patient care. (10) Currently, not all hospitals in Hong Kong
is able to provide these services, nor to the level required. Many patients requiring centralised
intravenous additive service or TPN service may not receive it due to insufficient level of
pharmaceutical service.
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PSHK Healthcare Reform Position Paper—August 1999
5.3 Control of antibiotics
Day in and day out, abusive use of antibiotics in Hong Kong has been prominent. This takes
place not only among the general practitioners (GP’s) but also within the hospital setting.
Pharmacists in overseas countries occupy an important position in rationalizing the use of this
class of drugs. Several general measures and principles can be employed by pharmacists in
conjunction with medical staff and microbiologists to better control the use and prescribing.
These entail of the following:
(1) Development of an effective antibiotic policy with certain key agents restricted to use
only after consultation with microbiologists or for use only with high dependency units;
(2) Drawing up guidelines for the treatment of both routine and more complex infectious
diseases, giving pharmacist ammunition to recommend changes in appropriate therapy;
(3) Acquiring knowledge of the hospital’s local resistance patterns;
(4) Monitoring the length of course for oral and intravenous antibiotics;
(5) Maximizing the first line therapy to reduce the number of treatment failures;
(6) Use of risk management through removal or restriction of agents from the formulary with
poor side effect profiles (12)
Hospitals in Hong Kong have begun to recognize this important role of a pharmacist. Similar
measures are already implemented in the large teaching hospitals. But again, the extent of this
service is not universal. The allocation of resources should be prioritised to reflect that this
could be one of the most important area for pharmacists to exercise their expertise.
5.4 Drug Information Service
The Chief Pharmacist’s office Drug Information Centre (DIC) was established in April, 1995
to provide accurate and timely information to questions raised by pharmacists. These
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PSHK Healthcare Reform Position Paper—August 1999
questions are very likely directed by the doctors and/or other professionals. In recent years,
drug information service has been more localised, being provided by pharmacists in
individual hospitals. These include:
(1) Drug information search, via

HALIS (Hospital Authority Library Information System): it is a compilation of
Micromedex databases which provide information on drugs, toxicology, reproductive
risk, etc.;

CD-ROM database reference resources;

Wide range of medical journals;
(2) Responses to drug-related diseases;
(3) Giving recommendations for requests of addition or deletion from drug formulary;
(4) Helping the development of drug use guidelines and drug use policies;
(5) Preparing and publishing drug newsletters;
(6) Coordinating the adverse drug reaction reporting;
(7) Providing in-service education.
The pharmacists providing drug information service, whether in the DIC or in individual
hospitals supply unbiased factual information in response to patient oriented problem. (13)
The enquiries encompass a wide range of aspects including pharmaceutical dosage forms,
usage, side effects, administration, storage, identification, even up to personal concerns, etc.
Often, a pharmacist is the ideal person to handle these enquiries due to the specific nature of
the questions on particular pharmaceutical products. However, often one centralised service
may not be sufficient to serve the urgent needs in the large number of public hospitals. The
idea setting is for each service area be equipped with its own drug information personnel, in a
localised setting, to be more efficient in handling enquiries and be able to support high quality
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PSHK Healthcare Reform Position Paper—August 1999
patient-care provided by other health care professionals. A drug information pharmacist is
almost a standard in every hospital pharmacy department in other advanced countries.
5.5 Other clinical pharmacy services
Kwong Wah Hospital is the first hospital that has established a warfarin clinic with
pharmacists’ intervention in the prescribing of the medication. As a result of this clinic, it has
been found that there is a gradual improvement in terms of pharmacist-patient and
pharmacist-physician relationship. Since counselling is provided on a more individual basis,
the relationship between patient and pharmacist can be closer. Patient compliance is also
assessed by close monitoring of INR (International Normalized Ratio) as shown by the blood
tests. (14)
Other specialist pharmacy services include diabetic clinic service, asthma clinic service, etc.
6. Setting up of a Monitoring System
In a system where from diagnosis to dispensing of drugs are performed by one person, there
are a lot of shortcomings in terms of efficiency and quality. Pharmacists are part of the health
care system. If there is separation of dispensing and prescribing in the system, prescriptions
can be screened by two health care professionals. The safety and quality of the prescriptions
are double-checked. This minimizes errors and is in the spirit of 'Continuous Quality
Improvement' with better service for patients. Data collection is also being enhanced as the
Harvard Consultancy report also emphasizes the need to establish an institute to collate
overall data and to overlook policy issues. Separation of dispensing and prescribing will assist
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PSHK Healthcare Reform Position Paper—August 1999
such institute to collect reliable and most updated data on drug usage from pharmacies as
current legislation has already governed the record-keeping of such data.
In a system where there is separation of dispensing and prescribing, it would facilitate
pharmacists help collect reliable data for an organization like the one the Harvard
Consultancy Report suggests, that is the Institute for Health Policy and Economics. This
would enable an objective and rational analysis to be completed. With this being
implemented, the health care system can then be better monitored.
All health care professionals should have a common vision and that everyone works towards
a common goal with the monitoring system. Professionals can help monitor each other to
achieve the objective of improving the service for patients. Evidence taken from the Queen
Mary’s Hospital has shown promising results in revealing that a monitoring system can help
screen out some of the potential errors made by the prescribers (6).
7. Complaints Channel
Apart from the professional body which governs one's own code of conduct, patients should
have a channel through which they can voice their opinions. In this way, any health incidents
happening to them, irrespective of the nature of it, can be reported to an independent
establishment. Data derived from here can help improve the system. There is a greater say for
the general public and various interest groups. In the present health care system, there exists
great variability in standard as there is no particular monitoring body to regulate as well as to
intervene. Through this public channel, professionals will build up heightened self-awareness
and self-discipline. The public will definitely benefit from it.
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PSHK Healthcare Reform Position Paper—August 1999
Conclusion
The pharmacy profession visualise a health care system wherein there is a true separation of
prescribing and dispensing to facilitate the realisation of all the benefits mentioned in this
paper. All in all, we do not agree that the separation of dispensing and prescribing be
immediately implemented without looking into the present health care infra-structure. There
is a lot of preparatory work that needs to be done in order to carry this out successfully.
However, it is the responsibility of the SAR government to commit itself for a better health
care system, hence endorse this complete separation of dispensing and prescribing system as a
policy.
Like other Western and nearby Asian countries, the separation does carry a lot of blessings to
their health care system. The positive impact surely is beyond words. Being pharmacists and
the citizens of the SAR, the eventual separation is really what we want to see. Not only will
this optimize the benefits of the patients as a “consumer” of health care, it will also be
contributory to the long term development of the policy of self-care and self-help. Overall
development of all other para-medical professions can balance out the present dominance of
one single profession.
At this point of time, no one is sure which financial model or what combination of models is
most suitable for the Government to adopt. In order to come to a decision of which financial
model, knowing the citizens’s social value is of paramount importance. Are the citizens of
Hong Kong ready to accept a risk-pooling concept? Or do they rather prefer paying for
themselves directly without insurance or health security plan? Without knowing what one is
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PSHK Healthcare Reform Position Paper—August 1999
to pay for, what quality care one is to receive, it is almost impossible to decide which
financial model works sustainably.
From the perspective of the pharmacy profession, we think that no matter what model Hong
Kong is going to adopt eventually, patients being the consumers of health care ought to share
the responsibility in terms of cost. The principle should be “money follows people” not
“money follows patients”. Are we encouraging people to become patients by adopting
unhealthy life-styles so that they can utilise the money? Right now, with insufficient
transparency, it is difficult to assess the quality of care as data collection is not at all easy.
However, with the true separation of dispensing and prescribing system, we think that there
will be an overall cut-down on health expenditure both to an individual patient and the
government in general. Notwithstanding, first and foremost, a proper environment needs to be
nurtured to achieve the separation of dispensing and prescribing system so as to ensure a
smooth transition.
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PSHK Healthcare Reform Position Paper—August 1999
References
1. Harvard Consultancy Report Executive Summary.
2. Bradley C., Blenkinsopp A., “The future for self-medication”, British Medical Journal
1996 Mar 30 Vol. 312.
3. Chinese University Press Conference 16 July 1999.
4. Cipolle R.J., Strand L.M., “A New Professional Practice”, A Pharmaceutical Care
Practice, McGraw-Hill: USA 1998.
5. Blenkinsopp, A., Bradley, C., “Patients, Society and the Increase in Self-Medication”
British Medical Journal Vol. 312 P.629-632.
6. Survey conducted by the Pharmacy Department of the Queen Mary Hospital. To be
published in the Hong Kong Pharmaceutical Journal. Currently available from the
authors.
7. Chen, C.M.L., “Reducing Polypharmacy”, Hong Kong Pharmaceutical Journal Vol. 6 (34) July-Dec, 1997.
8. Advertising Supplement to Nov 17, 1997 Issue of MacLean’s Magazine, “You and your
pharmacist – a healthy relationship” by Canadian Association of Chain Drug Store and
the Canadian Pharmacists Association.
9. “PSNC wants attention drawn to pharmacy’s health contribution”, The Pharmaceutical
Journal Vol. 260, May 2, 1998.
10. Gabos, C., Vaida, A.J., “Intravenous Admixture Systems”, Handbook of Institutional
Pharmacy Practice. 3rd ed. AHSP P.175-192
11. Hospital Authority Newsletter Issue 21, P.3 Dec. 1996.
12. Tritschler, I., “How pharmacists can help in rationalizing antibiotic prescribing in
hospitals.” The Hospital Pharmacist, Vol. 4 P.202-204, Sep. 1997.
13. Lee, P. Ma, E., “Establishment of a Central Drug Information Centre in Chief
Pharmacist’s Office, Hospital Authority” Hong Kong Pharmaceutical Journal Vol. 5 (3)
July-Sept, 1996.
14. Lau, M., Lee, S., et. al. “Benefits of Patient Counselling by Pharmacist in Warfarin
Clinic”, Hong Kong Pharmaceutical Journal Vol. 7 (3) July-Sept, 1998.
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PSHK Healthcare Reform Position Paper—August 1999
APPENDIX I
The Role of the Pharmacist in Self-care and Self-medication
Report of the 4th WHO Consultative Group on
the Role of the Pharmacist
Department of Essential Drugs and Other Medicines
World Health Organization
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