Index – Belföld – President of the Chamber: there are more risks than benefits of the medicine vending machines

In an interview with Index, Zoltán Hankó, the president of the Hungarian Chamber of Pharmacists (MGYK), spoke about, among other things:

• do medicine vending machines have the right to exist in Hungary;
• what is the Chamber’s position on the non-pharmacy distribution of over-the-counter products;
• what would be the best solution for providing services to disadvantaged settlements;
• touched on the reorganization of pharmacy services
• and to the amendment regarding branch pharmacies;
• he also revealed whether they are struggling with a shortage of professionals in the health sector.

At the Chamber’s last traveling meeting held in Mezőkövesden, the State Secretary of Health spoke about the fact that after primary care on-calls, the government is also planning to reorganize pharmacy on-calls, in which they do not shy away from unconventional solutions. One of these is the installation of medicine vending machines, which Péter Takács mentioned in connection with the fact that if there is no pharmacy nearby, adults can wait until the morning opening in non-urgent cases, but children’s medicines must also be made available at night.

Does the turnover of on-call pharmacies support this demand?

Our pharmacy has not had to take care for a long time, but according to the reports of my colleagues – mainly at night, i.e. after 10 pm – the demand for medicines is minimal, and this is also true for children’s medicines. On the one hand, however, the provision of continuous health care is a constitutional issue, so regardless of needs, health care must be able to be provided at some level even at night. I think a good initiative for this is the transformation of the primary care medical on-call and emergency system. On the other hand, it is necessary to be able to separate truly urgent needs from convenience services.

The home pharmacy is important

In larger cities, the experience is that some people take advantage of late-night walks in order to use their prescribed medicines two or three weeks ago. Regarding children’s medicines, the vast majority of parents are aware that the sudden nighttime illnesses of little ones are mostly related to feverish conditions and stomach and intestinal complaints. If there is no need for acute medical care, you can and should be able to prepare for the treatment of these conditions in advance. I would consider it important, and the pediatrician, the nurse and the pharmacist can also provide adequate help in this, which are the medicines that are important for small children, which should be kept in the home pharmacy with a box each. We have a professional proposal for this, and even to make certain medicines for young children free of charge – precisely related to the government’s family policy measures – which we have considered good for years in cooperation with the Civil Medical Association. In summary, the need at night is minimal, but in large cities and in 2-3 places per county, it may be justified to maintain a pharmacy on-call at night.

A home of almost 500 people research according to the survey, three-quarters of the respondents did not visit the on-call pharmacy in half a year. The MGYK on the side According to a previous survey also published, a quarter of them replaced the products prescribed in the doctor’s office, and 30 percent bought OTC, i.e. drugs available without a prescription, and 50 percent were convenience services. In the first case, according to the state secretary, most of the products are insured, the second can also be placed in vending machines, this can be an alternative to unprofitable night opening hours. What do you think about this? What risks does the method have in terms of patient safety?

It is my personal belief that medicines cannot be considered a simple consumer product that I take off a store shelf or take out of a vending machine, like a beer or a soft drink. Medicines – even non-prescription medicines – satisfy a functional need and it is not good if we treat their purchase as an experience purchase. They say that all medicines have side effects. Let me go on. According to various statistical data, in the European Union, the incorrect use of medicines results in additional costs of around 80 billion euros per year, 5-10 percent of hospital cases can also be traced back to this, and the incorrect use of medicines is said to play a role in the deaths of 220,000 people.

For example, many fever and pain relievers contain paracetamol, which some people may be sensitive to, or there are also pain relievers that irritate the stomach lining. Some can be harmful to the liver, kidneys, or interact with each other. That is why I do not recommend anyone to buy such products without consulting a doctor or pharmacist. Moreover, the use of certain dietary supplements can have negative consequences when taken together with certain medications.

In the United States of America, as approved by the FDA, pharmaboxes containing the most sought-after OTC preparations have appeared since the beginning of the 2000s, and in 2020, during the Covid period, they appeared in more and more places. Also during the epidemic, such vending machines appeared in some places in Italy, in small towns and shopping centers. In Austria, you can also buy fever and pain relievers, anticonvulsants, and hot drink powder from vending machines in front of certain pharmacies outside of opening hours. Like recently mentioned Hungarian pharmacists accepted patients even under the strictest restrictions. Why didn’t the question of vending machines come up then?

Let me start by saying that looking around the world we can find examples of almost everything and the opposite, but we have to solve our own problems, taking into account our own opportunities, cultural traditions and health literacy. In Hungary, since 2006, the question of medicine dispensing machines has been raised regularly. I remember that around 2008, a ministerial decree even introduced the possibility of setting up vending machines. This was removed from the legislation after 2010, but various investor groups have come up with this proposal several times since then.

There were several times that they wanted to introduce it in small settlements that did not have a pharmacy, and there were times that they wanted to supply penitentiaries with them. There was also an initiator who wanted to install 6,000 machines. A common element in all initiatives was that they wanted to be operated independently of pharmacies. In addition to the problem that I just mentioned, that medicine is a dangerous business, this also brought another problem to the surface: a significant part of rural pharmacies cannot afford to lose the distribution of a single box of medicine, because otherwise their conditions of existence will cease to exist. Do we install vending machines and close our pharmacies? However, the proposal of the Secretary of State differs from the previous ones, because he envisions the installation of vending machines as an alternative solution, tied to a specific purpose and operated by pharmacies. Here, weighing the risks and benefits and alternatives can result in a good decision.

Gasoline with painkillers

The possibility of distributing over-the-counter medicines outside of pharmacies was also opened in 2007, when OGYÉI granted licenses for 407 preparations. Hypermarkets and supermarkets, drugstores, and gas stations also got involved, but 580 stores withdrew, and ten years later only a few players were selling such products, the number of which has decreased to around 300 today. What is the reason why so many people have stopped selling drugs that generate profits in pharmacies? What is the chamber’s point of view regarding drugs redeemed at filling stations?

The decision on medicines that can be distributed outside the pharmacy is related to the 2006 pharmacy liberalization. I remember one of the leaders of the trade association at the time talking about 30,000 stores that were impatiently waiting for this opportunity, but in daily practice only a few hundred stores and gas stations undertook this. The traffic generated by these is also minimal, as far as I know, it does not even account for half a percent of all non-prescription traffic. My concerns about the distribution of medicines outside the pharmacy are primarily professional concerns, but I must say that the management of the pharmaceutical authority at that time took into account the risks inherent in the medicines and selected the distribution conditions that minimized them.

It cannot be sold over the counter, because, for example, the law does not allow the personal purchase of medicine for those under the age of 14. These medicines must be kept in a closed cabinet, where the storage conditions must also be ensured, including heat-, moisture- and light-sensitive medicines. Each such location must have a designated employee who is personally responsible for fulfilling the conditions. However, I know of quite a few cases where the expiry date was not observed or the medicines were obtained from an irregular place. And it is also a fact that the appointed person cannot give any professional advice because he lacks the competence to do so. Due to these circumstances, many people stopped selling. Last spring, the government also raised the issue of restricting the distribution of medicines outside of pharmacies, but since then I have no news as to whether this issue is still on the agenda. From a professional and ethical point of view, I am of the opinion that medicines belong in a pharmacy, where product safety and the necessary information for use are guaranteed by a specialist.

The issue of vending machines may also arise in the case of drug supply in disadvantaged settlements. Could this not be a solution in settlements where there is no pharmacy and you have to travel several kilometers to reach the nearest one?

A few years ago, we looked at how far the nearest pharmacy is to settlements without a pharmacy, and the majority of them are located within ten kilometers, but the question is legitimate.

In addition, the population’s health awareness and health status are generally worse. It can be even more risky for them to use medicine without the help of a specialist. It is therefore a legitimate social demand that the people living in such settlements should preferably have the opportunity to receive healthcare and, within that, medicine, locally.

The medicine rooms could come

We have several proposals based on each other in this regard. Where the operation of even a branch pharmacy is not a realistic expectation, there should be established special medicine delivery and reception places, so-called medicine rooms, where the needs sent to the nearest pharmacy in advance – and these can be not only medicines, but also other products that can be sold in pharmacies – can be delivered by name, according to the application with all information, the patient can receive it from the pharmacy employee in predetermined time slots. The prerequisite for this is that, for example, with the cooperation of the given municipality, a community place is designated where this special home delivery can be arranged. On the other hand, it is necessary to be able to establish a modern IT connection with the nearest pharmacy, where a personal consultation about substitution, dosage and risks can be solved during the “order taking”.

Another possibility – in even smaller settlements, typically with less than 500 inhabitants – is to connect patient needs with pharmacies by involving local government assistants. I know that in many small settlements in the country, the village caretakers have been helping for years, and during the Covid pandemic, the chamber developed a system of criteria that guaranteed the involvement of municipal assistants to those infected who could not leave their apartment, observing the aspects of drug safety, data protection, patient rights and hygiene. This system of criteria was also taken into account in an investigation conducted in the Borsod region, which was concluded at the end of March, and it could be a prospective solution even with a nationwide extension. Of course, direct contact between the patient and the pharmacy must be ensured here as well, so that the necessary control and information can be provided. We will report on the experience to the State Secretariat within a few days.

The Health Promotion Program of Attila Naszlady of the Maltese Charity Service served a similar purpose, which delivered medical care to the 300 poorest settlements with the help of medical assistants using telemedicine devices, but she objected to the way the medicines were delivered. What exactly was the problem with that?

I don’t think there is anyone who doesn’t respect the mission of the Maltese to provide care to people living in deep poverty and without access to health care. As a socially sensitive person and as a healthcare professional, I consider this mission important. I would like them to make use of our experience in the pharmaceutical solution of this, in order to avoid, for example, the creation of parallel structures and the drug safety, patient rights and professional-logistics problems that they have to solve. Likewise, it would have been good if they had discussed this with the specialists of the pharmaceutical factories and wholesalers in advance. We received a promise from the State Secretariat and the national chief medical officer that we can discuss these directly before the introduction.

In this context, we cannot go beyond what was mentioned earlier, that the number of pharmacists in the health sector is the most balanced here, but at the same time it is difficult to attract specialists to small towns and branch pharmacies. Couldn’t the new law provide a solution to this, according to which the presence of the specialist assistant will be enough, in online connection with the mother’s pharmacy? Or will wage demands also increase due to the greater workload, so there will be no reduction in expenses?

The legislation entering into force does not require an online connection, but stipulates that, if necessary, the possibility of consulting a pharmacist must be ensured within 15 minutes. My experience is that people don’t wait 15 minutes, and recognizing that there is a “problem” often requires competencies that pharmacists have.

In my opinion, the quality of patient care deteriorates in the most needy areas, the 15-minute waiting time for specialist advice is unrealistic, the recommendation of products suitable for individual problems, the screening of interactions and parallel drug use require legal and professional competences, which today only pharmacists possess. From a financial point of view, the situation of branch pharmacies will not improve.

In order to solve this problem, we should have looked at why branch pharmacies are closing, while there are more than twice as many pharmacists working in pharmacies today than there were 25-30 years ago. Moreover, there are more people than when the vast majority of branch pharmacies were established. In the latter period, it is not the number of pharmacies, but the total opening hours of the sector that is increasing, the reason for which is that those who accept longer opening hours or are on call win tenders for the establishment of new pharmacies, and this prompts other pharmacies to extend their opening hours as well, if they want to remain competitive . And this sucks the professionals from the countryside. I also see that today the operation of the 3,000 pharmacies does not cost the central budget money, because the amount that goes to the pharmacy margin from the distribution of subsidized medicines and is transferred to the central budget is returned to the budget from the pharmacies’ tax and contribution payments. There would therefore be room for maneuver to actually help branch pharmacies.

Returning to the transformation of pharmacy on-call services, isn’t it too late to start after the reorganization of primary care on-call services has already taken place in all counties, since the two systems are not independent of each other, as mentioned? In the case of pharmacies, according to which directive would the transition take place?

It would not have been a good idea to start at once, because it takes a few months to assess new needs. But I would have liked that in those counties where the reorganization of the primary care service took place, this would also happen two or three months later. What the Secretary of State said at the traveling assembly, according to which there is a need for a pharmacy open 2-3 nights per county, I think a possible way is to ensure the availability of a pharmacy near the primary care medical on-call during the on-call. It would be good if a stable, normative regulation were finally created, where constitutional expectations and objective necessity could be brought into harmony.

I would consider two aspects to be applicable at the same time, the availability of the primary care on-call service, and the population, as well as the number of kilometers within a radius of which a pharmacy on call can be reached. There should be a pharmacy available during the medical call, and during the emergency, i.e. from 10 p.m. to the next morning, the 2-3 pharmacy solution proposed by the State Secretary must be able to harmonize with the supply of large cities and county centers. Of course, local characteristics must be taken into account here as well. If there is a pharmacy in a place that is open continuously, i.e. 0-24 hours or on call, consider the issue solved. Only pharmacists can work in the emergency room, and I consider this to be good professionally, because you must be able to solve any situation for which only a pharmacist has the legal and professional competence. And one more thing: I’m always talking about emergency services. Pharmacy readiness is not justified, its full elimination must be solved as soon as possible.

Pharmacy robots

In more and more pharmacies, robots select and dispense medicines. Among other things, in a frequented pharmacy in Debrecen, the patient receives the requested preparation through the automated system. What future awaits pharmacists, if robots or artificial intelligence do not threaten their jobs?

These pharmacy robots make the work of pharmacists easier by not having to go to the warehouse for the medicine, but the robot delivers it to their hands. On the one hand, this means that you have more time to deal with the patient, which is very good. On the other hand, these robots also represent progress from a quality assurance point of view. the possibility of error in potency. My colleagues have reported positive experiences, but this is an expensive technique, and for the time being only pharmacies with a larger turnover can afford to purchase it. However, these robots do not and cannot replace the personal relationship between the specialist and the patient. It is also good for the patient if he receives his medicine from a specialist who looks him in the eye and who can help, not only with official information, but also with advice and a kind word. After all – and we often experience this – they are emotionally trapped because it is about their health, and believe me, no matter how much they think they know everything about their medicine, this is unfortunately not the case. And this personal relationship is also important because more and more patients come to the pharmacy without having met their doctor before.

(Cover photo: Dr. Zoltán Hankó. Photo: Péter Papajcsik / Index)