Three-Month Dispensing Not As Simple As It Sounds
May 30, 2003
Three-Month Dispensing Not As Simple As It Sounds
Pharmac's proposal to return to three-month dispensing for the bulk of medicines is not as simple as it sounds, the Pharmaceutical Society says.
Nor is it likely to result in greater convenience for a number of patients on long-term medication. A survey in one pharmacy revealed nine out of ten patients would still have to return to the pharmacy monthly to collect repeats for some of their medicines.
The Pharmaceutical Society of New Zealand says in its submission on the proposal, delivered to Pharmac today, that instead of offering greater convenience, it is likely to cause confusion among vulnerable patients, such as the elderly, mental health patients and those on multiple medicines' regimens. All of these people need greater levels of help with their medicines than three-month dispensing would allow.
Bernie McKone, Pharmaceutical Society President, said the plan was an exercise in cost-shifting not cost-saving. Instead of saving the Government $35 million, as promised by Pharmac, it would simply shift costs into other parts of the health system.
"This proposal means people will no longer have their pharmacist helping them to manage their medication each month. This will result in more doctors' visits as people try to sort out problems with their medicines, increased hospitalisations from inappropriate use of medicines and greater demand for residential care as elderly patients struggle to maintain their independence with complicated medicine regimens," he said.
"These costs will not be borne by Pharmac but by district health boards and the Government overall. Potentially they could wipe out the estimated savings on which Pharmac is basing this proposal."
Mr McKone said the Society supported three-month dispensing for people who were able to manage a large supply of drugs safely and whose medical conditions were stable. The best people to identify these patients were prescribers and pharmacists.
"The focus of the Pharmac proposal is wrongly on the medicines not the patient. It should be on how individual patients use their medicines, not whether a medicine is cheap enough to be dispensed in bulk."
The Pharmaceutical Society submission outlines the following impacts of the Pharmac proposal:
- Increased safety risks: the large quantities of medicines in people's homes will raise the risk of accidental poisoning, particularly of children, suicides and break-ins. Patients in their homes will become the new target for burglaries and break-ins by drug-abusers.
- Patient confusion: the sheer quantities of medicine some patients will receive (thousands of tablets and capsules, kilograms of creams and laxatives, litres of oral liquid medicines) will inevitably cause confusion. This will lead to under and over-use, no use if patients are overwhelmed by quantities and, for some, complete chaos.
- Pharmacy closures: pharmacies with high dispensing-to-retail ratios, particularly in small suburban and rural areas, will close. These pharmacies tend to be in economically-deprived areas with high Maori and Pacific populations, and a high proportion of patients on complex, long-term medicine regimens.
- High wastage: one of the reasons Pharmac abandoned three-month dispensing in 1996 was the high level of wasted medicines. District health boards will be required to run expensive "dump" campaigns to ensure large quantities of unused medicines are destroyed in a way that is safe for people and the environment. The Pharmac proposal does not allow for the considerable cost of these campaigns.
- Rest home services: pharmacists will not be able to absorb the costs of providing rest-home patients' medicines in safe and easy-to-use calendar packs. This will mean a return to dispensing medicines in bulk quantities for rest home staff to organise, distribute and store.
Submissions on the Pharmac proposal close today.
The Pharmaceutical Society is the statutory body protecting the public interest in the public's dealing with pharmacists. All pharmacists are members of the Society.
NB: Executive summary of Pharmaceutical Society submission attached.
Pharmaceutical Society of New Zealand
Submission on the
PHARMAC 3 Months' ("Stat") Supply Proposal
What is Supported?
The Pharmaceutical Society supports the dispensing of medicines in three months' single ("stat") supply for some people. The basis should be on patients' ability to manage such supply safely, not on the medicines they take. The decision over "stat" supply should be made together by the prescriber, the patient and the pharmacist.
Patients on long-term therapy who are stabilised on their treatment, compliant and competent to store and manage 3 months' quantities, are good 'candidates' for "stat" supply.
What is Not Supported?
The fact that the proposal is focused on medicines, and not on patients and their use of medicines.
The focus incorrectly is on lists of medicines - those that must be dispensed in 3 months' bulk supply and the limited number that may be provided monthly, or more frequently under close control provisions. Instead, the focus needs to be on patients, their use of medicines and the health outcomes that result.
Other Reasons for not Supporting the "Stat" Proposal
The "stat" proposal has significant and wide-spread implications in the following ways:
Increased safety risks - from the large quantities of medicines supplied at once being available in homes and communities to contribute to accidental poisonings, suicide and home invasions by drug misusers.
Vulnerable patients losing-out on regular contact with pharmacists - because they will receive bulk supplies and not visit the pharmacy again for 3 months. Compliance difficulties, adverse events with medicines and loss of therapeutic control cannot be monitored by the pharmacist. Increased hospitalisations may result form lack of medicines' monitoring by pharmacists.
Medicines' management in rest homes is threatened - because patients receiving their medicines in safe and easy-to-use compliance packaging will lose-out on receiving monthly, or more frequently-dispensed, packs. Unless they pay for these themselves, or rest homes absorb the costs, there will be a return to patients receiving bulk quantities, and a return to all the associated problems. Rest homes will not have the resources or expertise to manage risks around storing, administering and destroying the vast quantities of medicines that will ensue.
Loss of the public's access to pharmacies' services - pharmacies will close as a result of the "stat" proposal. The loss of income from dispensing places those pharmacies with a high ratio of dispensing-to-retail activity most at risk. These tend to be in lower socioeconomic areas and rural locations, and the threat to them jeopardises patients' access to pharmacists' primary health care services. The proposal is contrary to the Government's primary health care strategy.
Wastage of medicines - will be significant, as was the case when 3 months' single supply prescribing was practised in the 1980s through to 1996. The magnitude of the disposal problem means DHBs must implement costly DUMP programmes to ensure hazards to the public and the environment are minimised.
The PHARMAC Board must reject the proposal as formulated.
The real issue - is for health planners and funders, together with the pharmacists' profession, to determine how best to configure and fund pharmaceutical services. Pharmacists are seeking a greater role in primary health care in terms of medicines' management activities to achieve for people better health outcomes from their medicines' use. Dispensing is a component of medicines' management, and must be remunerated fairly for the activities involved. But, other ways must be found to remunerate for other pharmaceutical services. As part of that debate, issues around dispensing frequencies can be discussed, but in the wider context of pharmacists' medicines' management role.
Patients will not benefit - in terms of their health and safety. Non-complaint patients, and those whose conditions deteriorate, will go undetected for longer without more frequent contact with pharmacists. The benefits being promoted are ones of convenience only.
Nothing has changed -since 1996 with the policy to move from "stat" to monthly prescribing and dispensing. The sound public health and safety reasons for reverting to monthly supply remain just as relevant today as in 1996.
What is the Alternative?
- Fine-tune the existing exemptions from monthly dispensing to enable prescribers greater flexibility in prescribing "stat" supply for compliant patients able to manage long-term use of their medicines
- Implement targeted auditing and monitoring of "stat" supply arrangements to ensure they are being applied appropriately.
- Allow prescribers, patients and pharmacists to decide on the frequency of dispensing medicines based on the patient's individual health needs.