Primary Care Pharmacy – A Review of Current Situation and Future in Hong Kong
SO, Stephen Pak-Yina,b; YUNG, Johnny Chi-Honga; LI, Anson Yik-Tsuna; LEE, Marco Tsunb; WONG, Janet Kit-Tingb; CHENG, Franco Wing-Takb; LAM, May Pui-Sanb; CHIU, Philip Kwok-Leunga*; WONG, Ian Chi-Keib
a Mannings, The Dairy Farm Company, Limited, 8/F Devon House, Taikoo Place, 979 King’s Road, Quarry Bay, Hong Kong SAR, China
b Department of Pharmacology and Pharmacy, The University of Hong Kong, Hong Kong SAR, China
(*Corresponding author)
Over-the-Counter & Health
HKPharm J Volume 31 (1), Jan-Apr-2024 (2024-04-29): P.21-28
ABSTRACT
Hong Kong’s public healthcare system has been under intense pressure due to the aging populations and increasing chronic diseases prevalence. To tackle the challenge, the Primary Healthcare Blueprint was released by Hong Kong Special Administrative Region (HKSAR) Government which aims to develop a community-based primary healthcare system and promote primary preventive services. As part of the Government’s efforts to enhance the role of community pharmacists in primary healthcare system, Hong Kong pharmacists should broaden their scope of practice by utilizing their medication expertise to improve patient health outcomes, optimizing healthcare utilization, and fostering the collaboration within multi-disciplinary team. The Blueprint offered unique opportunities for community pharmacies to transform and expand their service scope, as long as the challenges and barriers are being addressed.
INTRODUCTION
Overloaded public healthcare system is no secret to people in Hong Kong (1). The annual attendance of Hospital Authority (HA) Specialist Outpatient Clinic (SOPC) has reached over 8 million visits in 2022 to 2023 (2). The number of Hong Kong populations with known chronic health conditions was 2.16 million in 2020 to 2021, which was 30.6% of total Hong Kong populations (3). It was projected to reach 3 million by 2039 (4). More alarmingly, a significant number of patients with chronic disease, estimated as much as twice the number of diagnosed cases, remain undiagnosed and untreated (5). With 75% of those over 65 suffering from chronic illness (3) and the elderly population expected to reach 2.52 million by 2039 (6), this trend will significantly increase healthcare demand and strain the system further.
Over the years, alleviation of the ever-increasing burden on the public healthcare system, in terms of high service utilisation and financial cost, has been one of the key focuses of Hong Kong Special Administrative Region (HKSAR) Government healthcare policies (1). The Primary Healthcare Blueprint was subsequently released in late 2022, aiming to transform Hong Kong healthcare system by shifting the focus from previous treatment-oriented secondary and tertiary healthcare to prevention-oriented primary healthcare (7). Primary care is the key process in health system that address the comprehensive health needs of a person at community level, integrating care, disease prevention, promotion and education (8). It is regarded as the most inclusive, equitable and cost-effective way to achieve universal health coverage (9). In recent years, there has been a growing demand for community pharmacy to be integrated within the primary healthcare system. The trend was further accelerated during COVID-19 pandemic (10). This article reviews the current landscape of primary care pharmacy in Hong Kong and explores the potential opportunities and challenges in the future.
PRIMARY CARE PHARMACY – REVIEW OF CURRENT SITUATION
Conventionally, the majority of primary care pharmacy in Hong Kong is limited to privately-owned community pharmacies, including both chain stores and independent for-profit pharmacies, serving the general populations. Despite studies in UK and US found that community pharmacists are the first contact point when people faced non-emergency medical issue due to lower cost to manage symptoms and less waiting time (11), local study found that medical doctors and Chinese medicine practitioners are the two most preferred healthcare professionals for seeking advice when people suffered from minor illness (12, 13). The reasons behind the discrepancy could be complex and multiple. In Hong Kong, medical doctors have both prescribing and dispensing rights. Patients with private medical insurance may preferentially visit private medical doctors for consultations with medications supplied at point of care. Medications self-purchased by patients at community pharmacies are often not covered by medical insurance unless they were prescribed by the medical doctors. This dynamic may contribute to the preference for seeking medical care from doctors. On the other hand, Hong Kong public healthcare services especially the Accident and Emergency (A&E) Department are well known of their relatively low fees charged to local residents and convenient access (14, 15). It serves as a safety net for the low income and underprivileged group despite study found that the service was commonly misused by the general public including those not in lower socio-economic class (14). Data from HA reported that over 60% of A&E visits were Triage 4 and Triage 5 cases, i.e. semi-urgent and non-urgent attendances. The number of cases were significantly higher than that in the UK, where only 33% of their A&E visit are reported non-emergency cases (15). Many of these A&E cases can be managed in the primary care settings (14). One last arguable issue was the medical certificate that is required for employees taking paid sick leave under the Hong Kong Employment Ordinance (16). Despite the fact that this may not be strictly enforced for short sick leave lasts for 1 or 2 days, its implementation often hinges on internal policies of individual companies. (12) While only medical doctors, Chinese medicine practitioners and dentists are authorised to issue medical certificates in Hong Kong (16), this may arguably skew local working populations to visit medical doctors for minor ailments. While the abovementioned health services predominantly favour medical practitioners, the role of community pharmacists was often under-utilised in Hong Kong. Consequently, this left many community pharmacies inevitably shift focus to sell general merchandise and home toiletries in order to ensure sustainability of their business.
Not until recent years, various primary care pharmacies operated by Non-Governmental Organisations (NGO) were established in Hong Kong. These non-profit primary care pharmacies, supported by various fundings, offer HA Self-Financed Items (SFI) prescription medicines at relatively affordable price. As a result, many patients visit these NGO pharmacies to seek pharmacist advice and services. Some of these pharmacies provided additional pharmacist-led health services including but not limited to medication management, minor ailment management, travel medicine pack, nursing home and various outreach services. With fundings from charities and sponsoring bodies, these NGO pharmacies play a significant role in primary care settings by providing community health services and affordable drugs for the population.
The establishment of District Health Centres (DHC) since 2019 marked another step forward by the HKSAR Government in developing primary healthcare. The model represented a horizontal integration of district-based primary healthcare with strategic purchasing and medical-social service collaboration, combined with vertical integration with secondary and tertiary care services through protocol-driven care pathway (7). This service model serves as a bridge between public healthcare system and community-based healthcare services to improve patient care across different settings. Community pharmacists actively engage in this multi-disciplinary setting providing various health education and services in the DHC (7). With progressively more DHC operators establishing primary care pharmacies and strengthen the local primary healthcare infrastructure, an expanding breadth and depth of collaboration between DHC and primary care pharmacies can be anticipated in delivering person-centered care.
OPPORTUNITIES FOR FUTURE DEVELOPMENT OF PRIMARY CARE PHARMACY IN HONG KONG
Over the past decade, there was a global growing trend to integrate services provided by pharmacists into primary care team, including Australia, Canada, the United Kingdom and the United States (17). Collaborations among healthcare professionals including pharmacists can improve communication and coordination. They are optimally placed to identify and address drug related problems, and can improve the availability and efficiency of healthcare (18, 19). Overseas model where pharmacists are integral member of the multi-disciplinary primary care teams has demonstrated extended roles in many direct patient care activities, including but not limited to medication management (18, 20), vaccination (21), disease screening (22, 23), and pharmacist prescribing (24). Primary healthcare blueprint by HKSAR Government clearly indicated the uniqueness of pharmacy services in primary care. This would facilitate primary care pharmacy to introduce more services-based models, which are driven by professional services collaborating with other healthcare providers across in different sectors. This section will discuss some of the service models from overseas and explore the potential applicability in Hong Kong setting.
Introduction of new specialised services in primary care pharmacies
- Minor Ailment Service
The usage of pharmacist service related to minor ailment is under-utilised in Hong Kong. Pharmacists can assess symptoms and consider any long-term conditions, and the medicines that patients are taking, before providing a recommendation for minor ailments. A recent introduction of minor ailment service by a local chain pharmacies in Hong Kong, in partnership with corporate business, is an innovative solution (25). Pharmacists will conduct a differential diagnosis and issue a pharmacist note to patient for submission to their companies as a proof of absence from work. A similar practice is under trial in Australia that the patients are exempted from work with pharmacist consultation for minor illnesses. This has proven to reduce the waiting time for employees at doctor’s clinics, reduce the claim and cost charged to insurance companies and eventually save on premiums during renewal (26)
A study In UK demonstrated that up to 40% of general practice (GP) visits were for minor illnesses which could likely be managed outside of the clinical setting (27). During COVID-19, integration of primary care pharmacy into National Health Service (NHS) UK was strengthened by delivering more clinical services and made primary care pharmacy as the first port of call for minor illness. NHS can refer patients to the pharmacies for advice and treatment. Over 2 million referrals have been made through this route and offload the workload of UK healthcare system during the pandemic (28). In Jan 2024, NHS introduced “Pharmacy First Service” where primary care pharmacies can supply over-the-counter (OTC) and prescription medicines to patients without the need to visit medical doctors, for seven common conditions including sinusitis and sore throat (28). This is an NHS-funded service which offers patients options to visit their community pharmacies for the self-treatable conditions who might have otherwise attended their A&E and doctors for treatment. The scheme has proven to be a cost-effective way to manage patients presenting to GPs with minor ailments (29). A similar service model could be learned and piloted in Hong Kong to ease the workload and long waiting time of public health services at General Outpatient Clinic and A&E. Community pharmacists can potentially play a more significant role in delivering minor ailment service, act as a health coach dedicated to improving the health and wellness of general public.
b) Vaccination
According to Guideline of Vaccination Subsidy Scheme by HKSAR Centre of Health Protection, vaccination administration is a medical procedure and it is the prime responsibility of the medical doctor in-charge of the vaccination arrangement in consideration of safety and liability (30). The vaccination should be administered by qualified healthcare professionals or trained personnel with at least one doctor, a registered nurse or an enrolled nurse to supervise on-site (30). While the University of Hong Kong offers immunisation training to pharmacists, collaboration with doctors and nurses will be required if pharmacists are to provide vaccination services in Hong Kong. This should not limit the potential role of pharmacists as immunisers since research has found that vaccination service conducted in primary care pharmacies boosted immunisation rate, increased access to vaccines and offered convenience for patients (31). Influenza, pneumococcal, herpes zoster, human papillomavirus and COVID-19 vaccines are some of the common vaccines administered by pharmacist immunisers in primary care pharmacies (32). However, the types of vaccines and age groups that pharmacist can administer vary by country and are influenced by local guidelines and regulations (33). The future development of a primary care health hub with multi-disciplinary healthcare professionals providing one-stop service should be further explored.
- Health Screening
Health screening is a prevention strategy that seeks to identify chronic diseases and limit the associated disability by early detection and treatment (34). It was shown to improve patients’ quality of life by preventing the onset and reducing complications of the chronic diseases (35). Various disease screening models and point-of-care tests are available in primary care pharmacies such as cancer screening, asthma, chronic obstructive pulmonary disease, osteoporosis, depression, hypertension, hypercholesterolaemia, and diabetes (22, 23, 36-38). High-risk individuals will be referred to the family doctors for further assessment and treatment follow-up. Research indicates that the key advantage of screening services through primary care pharmacies are the convenience of access, both in terms of location and opening hours, and cost-effectiveness (38, 39). Primary care pharmacies, often the first point of contact for patients, provide an optimal setting for community pharmacists to screen, educate and support patients in disease prevention and self-management with the assistance of diagnostic medical devices and test kits. Pharmacists are in a unique position to provide screening services to improve patient health outcomes (40).
- Medication Management Services
Medication management services (MMS), defined as “spectrum of patient-centered, pharmacist-provided, collaborative services that focus on medication appropriateness, effectiveness, safety, and adherence with the goal of improving health outcomes”, has been conducted worldwide (41, 42). Some are subsidised or contracted by the government such as the UK and Australia (43, 44). In the UK, two of the examples of MMSs are Medicines Use Reviews (MURs) and the New Medicine Service (NMS) performed by community pharmacist. They were first introduced in 2005 on a basis of contracted services, requiring community pharmacists who chose to deliver them to receive training and to meet specified service requirements (45). These services are free to patients. Remuneration for contracted pharmacies from the NHS is £28 per MUR, up to a maximum of 400 per year, and up to £28 per NMS depending on numbers completed. The MURs aim to improve patients' understanding of their medicines and adherence, particularly among those with chronic conditions, highlight problematic side effects and propose management where appropriate, as well as reduce medicines wastage (45). The NMS targets people with long-term conditions and newly prescribed medication to improve their medicines adherence, and there is also an explicit aim for the NMS to support patients in making decisions about their treatment and self-management. A systemic review demonstrated that MMS improved patients’ clinical status by effectively reducing the rate of re-admission, A&E visit, adverse drug events and drug-related problems (46). A cost-analysis study showed that MMS is a cost-effective measure to improve the quality of life of the population with chronic disease, compared to usual care (47).
e) Pharmacist Prescriber in Disease Management Services
The concept of pharmacist prescribing was pioneered in the US in the 1990s (48). In general, pharmacist prescribers are legally authorised to prescribe, supply and administer medicines, despite their actual role and prescribing rights vary in different countries (48, 49). Additional training is required and pharmacists have to enrol into a specific register with regulatory authorities of their countries before practice. In most states of the US, pharmacist prescribers work collaboratively with medical doctors under collaborative practice agreement (CPA). The pharmacist prescriber assumes responsibility for specific patient care functions that are otherwise beyond their typical scope of practice, but are aligned with their education and training. This included the initiation and modification of drug therapy, undertaking a physical examination, and ordering laboratory tests. The extent of services authorised under the CPA depends on individual state regulations and the terms of specific agreement between the pharmacist and medical doctors (50, 51). In UK, pharmacist independent prescribers (PIP) can autonomously prescribe a wide range of medicines for conditions within their scope of practice and clinical competence (52). These services include providing medicines for minor short-term illness, chronic conditions involving dosage adjustments of medicines, referral to other healthcare professionals, follow-up care and deprescribing (52, 53). While in most territories of Canada, pharmacists have limited powers but can provide emergency prescribing and extend prescription services (54).
A systemic review of sixty-five studies from the UK (n = 34), Australia (n = 13), Canada (n = 6) and the USA (n = 5) found that mostly positive experiences and views towards pharmacist prescribing were reported by patients and healthcare professionals including doctors and pharmacists (55). The major benefits reported were ease of patient access to healthcare services, improved patient outcomes, better use of pharmacists' skills and knowledge, improved pharmacist job satisfaction, and reduced physician workload. The reported challenges were largely associated with accountability for prescribing, limited pharmacist diagnosis skills, lack of access to patient clinical records, and issues concerning organisational and financial support (55).
Some of these models discussed were similar to our disease management service provided by public hospitals under HA in Hong Kong. One example was the pharmacist-led warfarin clinic, where clinical pharmacists can renew or adjust warfarin dose or make referral to specialists when needed according to mutually agreed protocol(56). Other pharmacy service models in Hong Kong primary care settings, on the other hand, are yet to be developed. Given the HKSAR Government initiative in enhancing the role of community pharmacies in primary healthcare, primary-based pharmacist-led disease management service models should be explored with the aim to improve patient access to healthcare services, improved patient outcomes, and to ease the workload of public healthcare system.
Public Private Partnership
In order to shift patients from the overstretched public healthcare system to primary healthcare, collaboration between public and private sectors should be adopted. During COVID-19 pandemic, patients with chronic diseases have restricted access to HA SOPC due to rescheduling of appointments or patients’ fear of returning to hospitals. Some patients could not access to refill their chronic medications. In view of the gap, a Hong Kong local pharmacy chain has launched a hospital medication collection service since April 2020 (57). The service offered options to patients to collect their long-term HA medications at the community pharmacies without the need to return to hospital during the pandemic. Community pharmacists provided counselling to these patients during medication collection. Future services including having HA drug refill dispensed in primary care pharmacies should be explored (7). Patients with chronic disease who are in stable conditions would be ideal candidates to access such service as an alternative to frequent visits to SOPC and HA pharmacies (58).
Health Education & Promotion of Self-Care
Self-care is defined as “the ability of individuals, families and communities to promote health, prevent disease, maintain health, and cope with illness and disability with or without the support of a healthcare provider (doctor)” (59). It shows empowerment of patients to manage their health and well-being actively (59). As populations grow and health needs diversify, the need for access to medical care and the reliance on self-care will continue to grow.
Health services in workplace settings are also another way to promote health education and self-care of chronic diseases. A study included 573 diabetic employees from 10 geographic locations receiving consultations from pharmacists to achieve their clinical and self-care goals (60). On average, pharmacists received an estimated $391 USD per patient in total with an average of 6 visits per participant. Patients showed significant improvement in clinical parameters including haemoglobin A1c (HbA1c), low-density lipoprotein cholesterol (LDL-C), blood pressure and body mass index (BMI). The total cost-savings during the first year of program implementation were estimated at $339,875 USD for patients and $278,512 USD for employers. This service may also encourage patients to receive influenza vaccinations, eye examinations and foot examinations. Another program also enrolled employees for regularly follow-ups with community-based pharmacists on diabetes or hypertension coaching program respectively (61). Blood pressure and LDL-C values improved significantly from baseline for both groups, and within the diabetes cohort, mean HbA1c levels improved significantly. The above showed that pharmacists have demonstrated value for improving patient outcomes, providing cost-savings, and ultimately benefiting individual wellness through a preventive health approach.
In Hong Kong, self-care is not adequately emphasised. Patients tend to seek medical advice from doctors for minor ailments, or seek medical information from non-credible source (12). Low health literacy is a common issue and it is a barrier to self-care, particularly in those with lower socioeconomic status, limited education and older adults (62). Public may not be aware of the role of community pharmacists, who can provide “over the counter” medicines and advice that can help alleviate symptoms (27). Pharmacists can build up a “shame-free” environment in which individuals can ask questions as well as receive non-judgmental answers and encouragement to improve their well-being regardless of their level of health literacy. Consultation rooms in the primary care pharmacies can also provide a more suitable and private environment for patients to express their questions and concerns. Future collaboration between DHCs and primary care pharmacies in Hong Kong for management of minor ailments, two-way patient referral mechanism, drug refills with counselling services and case management on chronic disease can be further explored to empower patient on self-care and improve the health literacy (7).
CHALLENGES, SUSTAINABILITY AND WISHLIST
Despite the well-recognised accessibility of primary care pharmacies to patients, several issues and barriers would need to be addressed to ensure sustainability of pharmacist-led health services. These include health record sharing, regulatory barriers, continuous professional development and remuneration of services.
Enhancement of electronic Health Record Sharing System
Developed by HKSAR Government, the electronic Health Record Sharing System (eHRSS) is a centralised digital health record platform for patients and multidisciplinary healthcare professionals. The system enables two-way sharing of patients’ health record among healthcare professionals practicing in public and private sectors (63). Upon consent by patients, community pharmacists can access patients’ health record in eHRSS, conduct pharmaceutical services and provide various preventive health services. However, community pharmacists are not considered as network service provider and no clinical documentation can be input into eHRSS under current system, which acts a barrier to clinical information sharing and collaboration with other healthcare professionals. Current system only reflects prescribing and dispensing histories without actual medication usage. This undermines continuity of care and patient safety. System enhancements would be required if primary care pharmacies are to be better integrated into primary healthcare systems and play a bigger role in delivering various health services. This would facilitate the dialogue and collaboration between pharmacists and other healthcare professionals.
Regulatory Barriers
Current regulations in Hong Kong restrain pharmacists from extending their practice scope. Some of the service models discussed in this article required amendments to regulations. One example is the pharmacist prescriber service, which may include prescription modification and optimisation, from dose adjustments to substitution of therapy according to the protocol, will require regulatory amendment (50). Same as if the community pharmacists are to provide emergency supply of existing prescription drugs to patients for continuity of care, in reference to the service model of Canada and UK (28, 54). Health screening is another example as routine service provision by other healthcare professionals will be required unless a regulatory framework is established for pharmacists to conduct point-of-care blood testing. Government and policymakers should address the regulatory barriers when introducing new pharmacy services, despite this not hindering the potential role of community pharmacists in primary care settings.
Continuing Professional Development for Pharmacist
Continuing Professional Development (CPD) is an ongoing, self-directed, structured, outcomes-focused learning cycle that focuses on maintaining and improving performance of professional practice (64). It does not replace traditional Continuous Education (CE), but rather enhances CE in a broader approach which ensures pharmacist competence and performance (65). In Hong Kong, no CE nor CPD are required for pharmacists to renew annual practising license. However, as the healthcare environment changed rapidly with technology advancements, the role of pharmacist has been undergoing transformation worldwide (66). CPD has become crucial for pharmacists, not to just keep up the latest development and innovation in the field, but also to develop new skills and gain a broader understanding of all aspects of pharmaceutical care. Since the HKSAR Government aims to enhance the role of community pharmacists in delivery of primary healthcare services (7), CPD for pharmacists is suggested and should be made mandatory in the long run. This is vital to ensure pharmacists are adequately trained and equipped to deliver high-quality care and service to patients.
Remuneration and Reimbursement of Pharmacy Services
Preventive health and MMS led by pharmacists have been demonstrated to improve patient health outcomes, reduce healthcare costs and justify the need for a proper reimbursement model to remunerate pharmacists for their professional services (67-70). Various remuneration models are available in other countries where governments pay and reimburse community-based pharmacist-led clinical services (69, 71). In Hong Kong, however, such reimbursement models are yet to be developed and do not incentivize pharmacists to devote their time and effort to provide preventive health services. A higher opportunity cost is needed for pharmacy services in comparison to dispensing prescriptions and selling OTC medicines and supplements. Reimbursement from the government is especially important for pharmacist-led health services to make the services sustainable, as these services are often not covered by medical insurance (72). Refit of pharmacy premises with private consultation room installed are also required before service launch. This will help ensure that pharmacists secure the resources required to provide high-quality care to patients, including access to the latest medications, space, equipment, and technology (73). Proposed reimbursement models by the individual patient, type of visit (initial versus follow up), service provided, or time spent with the patient are suggested and should be further explored (74).
CONCLUSION
Transformation of Hong Kong healthcare system is underway. Collaboration is vital to success. Pharmacists can play a greater role in the new primary care system, by providing various specialized health services to keep our local citizens healthy, and leveraging pharmacists as health coaches. Different funded pharmacist-led service models shall be explored for future development of primary care pharmacy. Pharmacists engaged in primary care setting shall embrace the opportunities, prepare and build themselves as a trusted health and wellness partner of the public.
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Author’s background
SO, Stephen Pak-Yin is the Health and Research Manager at Mannings, Honorary Lecturer at the Department of Pharmacology and Pharmacy, the University of Hong Kong. His email address is stephen.so@dfiretailgroup.com
YUNG, Johnny Chi-Hong is the Health Innovation Manager at Mannings. His email address is johnny.yung@dfiretailgroup.com
LI, Anson Yik-Tsun is a registered pharmacist at Mannings. His email address is ansonli1027@outlook.com
LEE, Marco Tsun is the Senior Pharmacist at the Department of Pharmacology and Pharmacy, the University of Hong Kong. His email is marcolt@hku.hk
WONG, Janet Kit-Ting is the lecturer at the Department of Pharmacology and Pharmacy, the University of Hong Kong. Her email is janetwkt@hku.hk
CHENG, Franco Wing-Tak is the lecturer at the Department of Pharmacology and Pharmacy, the University of Hong Kong. His email is francowt@hku.hk
Dr. LAM, May Pui-san is the lecturer at the Department of Pharmacology and Pharmacy, the University of Hong Kong. Her email is maypslam@hku.hk
CHIU, Philip Kwok-Leung is the Head of Professional Service at Mannings. He is the corresponding author and his email address is philip.chiu@dfiretailgroup.com
Prof. WONG, Ian Chi-Kei is the Head, Department of Pharmacology and Pharmacy, the University of Hong Kong. His email address is wongick@hku.hk