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Pills and potions

Cathy Holcombe, writing in the current issue of Spike, highlights a pharmacy in Central that is apparently famous for offering controlled medicines without a prescription. She also reports that it's cheaper than Watsons. I am sure that's right - I have briefly touched on the subject of Hong Kong pharmacies, and at the time I made the observation that independent pharmacies are always cheaper than Watsons and Mannings, and often significantly so. It’s also true that pharmacies seem quite eager to dispense "controlled" medicines without the doctor's prescription that is legally required.

The most egregious example I have personally come across was when I was asking for something for a sore throat and was offered antibiotics, but it seems quite routine for them to dispense medicines on request, usually after they have been prescribed by the doctor. Just bring along the small plastic bag that the doctor gave to you with 3 or 4 days supply of medicine and the pharmacist will sell you some more. Or if you have a doctor's prescription they will sell you the medicine but let you keep the prescription for future use (which is not how it is supposed to work).

The UK system separates the roles of doctors and pharmacists (the doctor gives you a prescription, you take it to the pharmacy for the medicine to be dispensed, the prescription then gets passed to NHS bureaucrats, who pay the pharmacist). If you need to take a particular medicine repeatedly, you either have to request a new prescription each time or set up an arrangement with a pharmacist (who will check with your doctor that it is OK). Whichever way you choose, the doctor will want to see you regularly to check that the medicine is working and monitor your health condition.

In Hong Kong, doctors normally dispense the medicines themselves, but do sometimes give you a prescription. However, in practice you could then carry on buying the same controlled medicine from the pharmacy for years without ever seeing a doctor (though frankly that would be rather stupid).

The main point of Ms Holcombe’s (rather lengthy) article in Spike is that the pharmacy in question is breaking the law, and yet it seems to be impossible to obtain details of any past prosecutions. In fact, it seems that there haven't been any prosecutions, which in turn raises the question as to why this should be if the law is being broken quite consistently.

What is more interesting to me is whether this law-breaking is inevitable given the system in place, and whether it is a good or a bad thing, and Ms Holcombe does touch upon these issues at the start of her piece. She is in favour of doctors dispensing medicines, but for reasons that I find slightly puzzling. Her argument is that in the USA even if you have flu it is necessary to get a prescription from the doctor, and then go to the pharmacy to pick it up.

This actually sounds like an argument in favour of allowing pharmacists to dispense some medicines, which is how things work in the UK. If you have a cold or other minor ailment, you can visit your local pharmacist and he will ask you a few simple questions and may then offer to sell you certain medicines that you cannot buy elsewhere (or direct you to the doctor if it is more serious). I think that a similar system does operate in Hong Kong, and I'd be surprised if it wasn't also the case in the USA, but clearly the usefulness of such arrangements very much depends upon what medicines are covered - in the UK, it includes many medicines that were originally only available with a doctor's prescription, but I am not sure about other countries. So although I'd agree with Ms Holcombe, I think we are talking about a different problem.

In Hong Kong there seems to be a tradition of people visiting the doctor for even very minor ailments (and being given four or five small bags of pills as a reward). I could understand pharmacists feeling a bit frustrated about that, because they are clearly losing business, though some people do go to the pharmacy when they have a cough or cold (myself included) - what I don't know is whether pharmacists then break the law by dispensing medicines that they shouldn't.

Mannings and Watsons seem to believe that there is an opportunity here, and have increased the number of pharmacy counters. As you might expect, they are very careful about following the law (when I purchased some cough medicine I had to provide my personal details) and they are also much more expensive, and only open limited hours. Mind you, the counters are clean and tidy, and pharmacists are dressed in white coats to provide added reassurance. I think I’ll stick with my local pharmacist who is open all hours and charges less, but each to his own!!

I'm not really qualified to judge whether it is better or worse for patients to have the doctor dispensing medicines. Yes, it's more convenient for most people, and it involves less bureaucracy, but you don't have a qualified pharmacist checking the prescription before it's issued. In my experience, Hong Kong doctors rarely tell you what they are prescribing, and the nurse who gives you the medicine rarely says anything more than what is written on the packet ("take three times a day, before meals"), whereas UK pharmacists usually check whether you have had the medicine before and will explain a little more about how to take it and whether it might have side effects.

Should we be concerned about this? In general, I'd say not, because most people are either getting medicines that are generally harmless, or medicines that have already been prescribed by a doctor. However, I do worry about antibiotics being offered on general sale, not because it will do any harm to the people who buy and take them, but because it increases the chances of the bugs building up resistance and so eventually making the drugs ineffective. It's clearly unprofessional of a pharmacist to do that, and I hope that is an exception rather than the rule (though I would also argue that the problem has been created in the first place by doctors over-prescribing inappropriate medicine).

Assuming that pharmacists are normally only dispensing drugs sensibly, I feel sympathy for them because they are providing a useful service. As a patient, if you've been to the doctor but still aren't feeling better would you rather pay $150 for another short consultation and more small bags of pills, or $50 just for extra medicine? As a pharmacist, would you feel that there was anything wrong in offering this service? I doubt it. The current system encourages the pharmacist to offer a service that is undoubtedly illegal, and that cannot be right.

So it may be time for the appropriate authorities to look again at how the whole system works Doctors and pharmacists have different and complementary expertise, and it would make sense to find a way for them to work together more effectively. However, there are probably too many vested interests involved for that to happen anytime soon.

Comments

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henry

let me give you an example...

whilst in the UK, we were out and about in manchester one time, and one of the people in our party (who was an asthmatic) realised that they were about to have an attack.

they had also forgotten to bring their inhaler with them..

so we trolled into boots, he sat down and have them his card from the doctor saying that he was an asthmatic, but boots were adamant that they couldn't give him an inhaler without a prescription!

in the end, he had his attack, and we spent 5 hours in a hospital whilst he was in a nebuliser tent.

for that sort of reason, I'm really glad that HK pharmacies will sell you prescription drugs without a prescription.

you also have to bear in mind that the guys who run these places are switched on, so if you are asking them for serious prescription drugs, they will refuse you.

you can't turn down an asthmatic on the verge of an attack because of some stupid beaurocratic rule that says he needs a doctor's signature, even though he knows what he needs!

Chris

Well, it shouldn't work like that. The pharmacist in Boots should have called the person's doctor and checked that it was OK to give them an inhaler. Assuming the doctor confirms it is OK, they can dispense it immediately. I have seen this done more than once. Sounds like someone in that branch of Boots didn't know what they were doing!

I am not sure how it is supposed to work in Hong Kong, but you are right that in practice the pharmacist would probably sell you an inhaler. However, they would be breaking the law!

BWG

Chris, I once ran into a problem trying to get a bottle of Advil.

It's available over the counter in Canada. When I went to Mannings, they told me they couldn't give me any (under lock and key behind the counter) because the pharmacist was off duty.

I picked up a bottle at the corner dispensary 5 minutes later.

Chris

There is no apparent logic to what is available over-the-counter and what is controlled, and it certainly varies by country.

The most annoying thing about Mannings and Watsons (apart from the high prices) is that they only have a pharmacist on duty at certain times. As you say, your local corner shop pharmacy will be much more obliging.

In fact, in Hong Kong I can think of very few examples where a large chain store has any advantage over a small shop!

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