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Letter to the Hospital Authority on the Drug Formulary

posted Nov 23, 2009, 8:46 PM by DERC 藥物教育資源中心   [ updated Nov 23, 2009, 8:50 PM ]

(Originally posted on 2006-05-29)

The General Committee received a letter from the Hospital Authority to solicit views about the HA Drug Formulary. The following is our response.

Dear Dr. Cheung,

This correspondence is collectively authored by the General Committee of the Society of Hospital Pharmacists of Hong Kong ("SHPHK") as the Society's official response to the captioned letter from Dr. W. L. Cheung dated 4th May 2006.

We quote from our letter of 29th April, 2005, sent to the Hospital Authority ("HA") as our response to its public consultation on the Hospital Authority Drug Formulary ("HADF"): "SHPHK commends HA on taking a bold, proactive step towards rational use of drugs, and looks forward to working with HA to implement changes brought on by the HASDF [now the HADF] that are beneficial to patients, the general public and the society." We continue to stand by this statement.

We also continue to stand by our conviction that the HADF's only objectives should be, as we quote from our previous letter, "to provide equitable access to, and to promote rational use of, cost-effective drugs of proven safety and efficacy."

Since the introduction of the HADF in July 2005, the two aspects of the HADF that have caused the most dissent among patients, the public, health professionals, some business sectors and politicians are: (1) the mode of supply of self-financed items; and (2) mechanism of the safety net. Both aspects of the HADF are financial rather than clinical issues; we have already advised in our previous letter that there should be no financial element in the HADF, lest they should corrupt the Formulary's original objectives; our advice went largely unheeded. The controversy around these two aspects of the HADF over the past few months once again compels us to reiterate that the design of the HADF should be decoupled from any financial considerations.

For this reason, we advocate the following:

(1) HA should not sell self-financed items (beyond what it is already selling)

At the time of writing, it has been widely reported in the media that HA plans to expand its drug selling operations. We strongly recommend against this plan.

Impact on society: The operation of a drug selling business is completely outside the HA's role as a public health service provider, and is completely irrelevant to the 4 targeted public service areas proposed in HMDAC's discussion paper of July 2005 ("Building a Healthy Tomorrow"). By directly entering the private market, HA will be suffocating any further room for development of the public-private interface, further marginalising private health providers such as private hospitals and community pharmacies.

Impact on the general public: (1) Under the HADF's current design, patients are referred to the community for non-formulary drug items. Thus the HADF shows considerable potential to become an educational tool for the public, so that the public knows that both the public and private sectors have roles to play in the provision of care. By selling SFI's, this potential no longer exists; the HA retains patients within the public system, further reinforcing the imbalance of public and private health sectors. (2) Dr. Cheung's letter states that some groups believe HA should sell SFI's directly because "patients, unlikely to be knowledgeable about drugs, would find it difficult to ensure their quality and composition." If there are drugs of dubious quality and composition on the market, it is a law enforcement and legislation issue. Directly entering the market is not a valid answer and will not help solve the issue. The correct response is to advocate that the HKSAR Government takes steps to amend outdated pharmacy laws and step up law enforcement.

Impact on patients: We are proud of our public hospital's advanced drug prescribing and dispensing system. It is a system that emphasises check-and-balance and promotes rational use of drugs. The HADF has until today helped to enhance this system. However, by selling drugs where they are prescribed, we risk disrupting the system and introducing a cause-and-effect relationship between what a public doctor chooses to prescribe and the hospital's revenue. This undermines patients' trust that doctors will always act in their best interest.

(2) The "SFI with safety net" category should no longer exist

SHPHK supports the concept of shared responsibility between individuals and the public health system, and believes that it is absurd to have one type of shared responsibility for "General" and "Special" drugs, and a different type for "SFI's with safety net".

The reason that "SFI with safety net" is causing much controversy is its very existence. Rather than spending efforts to refine the safety net mechanism, we recommend to abolish the "SFI with safety net" category altogether. Items currently in the category should be re-classified as "General" or "Special" drugs if they are proven to be drugs of benefit. One common drug charging and subsidising mechanism should then apply across all drugs for all patients equally.

To conclude, the HADF introduced last July has its merits - promoting the rational use of drugs - and its vices - allowing itself to be corrupted by financial concerns. We strongly recommend that at the next revision of the HADF, the Hospital Authority works to eliminate the vices rather than perpetuating them.

Yours sincerely,
Ng Kim Wah, President,
The Society of Hospital Pharmacists of Hong Kong
On behalf of the General Committee

C.c. Mr. Anthony Wu, Chairman, Hospital Authority; Mr. Shane Solomon, Chief Executive, Hospital Authority