MOH to stop GP clinics from selling medicine


Index

  • MOH to stop docs from selling drugs  (1 Jan 05)
  • Forum responses to above article   (5 Jan 05)
  • MOH: Split of drug prescribing, dispensing not likely soon  (7 Jan 05)
  • Dispensing with dispensing doctors?  (9 Jan 05)
  • No lobby against split of prescription, dispensing   (13 Jan 05)
  • 10 Questions Hobbit Would Like to Ask Ms Salma Khalik  (Jan 05)
  • Notes of Meeting between DMS and Salma Khalik  (3 Jan 05)
  • Liberalise distribution of prescriptive drugs  (Forum) (27 Feb 06)
  • Patented drugs keep medical costs high in S'pore  (Forum) (16 Mar 06)
  • Docs dispensing drugs: System not without its benefits, says Khaw  (21 Sep 07)
  • Straits Times editorial on above statement  (24 Sep 07)
  • Separate drug dispensing: Educate the public first  (26 Sep 07)
  • Making Doctors Stop Dispensing  (27 Sep 07)
  • Here's a win-win prescription  (27 Sep 07)
  • Pharmacists help to ensure safe and right use of drugs  (29 Sep 07)


    Questions for discussion Return to Main Medical Index


  • MOH to stop docs from selling drugs
    Move will take years as their income closely tied to medicine sales

       SINGAPORE is slowly moving towards separating a consultation with a physician from his selling the medicine he prescribes, a practice common in developed countries, the Health Ministry revealed.

      The goal departs from MOH's usual stand of supporting the existing set-up, which has opened doctors to the criticism that some prescribe drugs that give them a better profit, rather than ones that are cheaper but just as good.

      However, MOH told The Straits Times, it will take years before the two functions are done by different people, as the income of a doctor in the private sector is linked very closely to the money he makes from selling medicine to his patients.

      The ministry's director of medical services, Professor K. Satku, explained: 'This is something that touches people's rice bowl, so you cannot charge in and change it. We must prepare our doctors.'

      Without phasing in the change, patients could be slapped with heavy consultation fees as doctors try to make up for their lost income and overall health-care costs could go up. He said though that doctors would still be allowed to sell certain medicines, such as those that need to be administered quickly.

      The change is prompted by the expected heavier call on doctors' services as the population ages. Removing the task of selling medication, Prof Satku added, would allow them to 'concentrate more on the care and counselling of patients, rather than the prescription of the drugs'.

      In countries like the United States and Australia, doctors charge only for consultation. They prescribe what patients need and the patients have to buy the drugs from a pharmacy. This way, doctors are not swayed by the possible profit they could make from selling a drug directly.

      A general practitioner (GP), who has a clinic in Bukit Timah, argued that changing to such a method could cut both ways. 'If I have no interest in the cost of the drug, I'd just prescribe 'the best', which may be the most expensive. I can't do that today. The market is very competitive and patients vote with their feet,' he said.

      The change will have little impact on medical groups, said Parkway Shenton's executive director, Dr Goh Jin Hian, as his group would simply set up a chain of pharmacies.

      While the change may make doctors appear more impartial, a GP in Jurong pointed out that many patients like the convenience of getting their medicine from the doctor. He said: 'My diagnosing food poisoning in a patient at 9pm on a Saturday night is one thing. For him to have to go to the nearest pharmacy that is still open for his prescribed medicine, while suffering bouts of diarrhoea and vomiting, is another thing altogether. 'Any of my patients will say: Just let the GP give me my medicines, and let me go straight back to my flat in the next block and crawl into bed.'

      But Prof Satku argued that Singaporeans need to learn that they should have some medicines at home for common ailments like diarrhoea and fever. He also foresees the setting up of more pharmacies to cater to people's needs, with at least one in each suburb, and that these would stock generic drugs, something such outlets in the private sector rarely do. 'Generics save the patient considerable cost. We need to address this too as we roll out changes in policies,' he added.

    The Straits Times
    01 Jan 2005

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    Letters to the Straits Times Forum on the above article
    Stopping docs from selling drugs a bad move

       I REFER to the Ministry of Health (MOH)'s move to stop doctors from selling medicine that they prescribe ('MOH to stop docs from selling drugs'; ST, Jan 1). I am not a doctor but I am surprised that MOH would introduce such a move without consulting those that would be most affected, that is, members of the public.

      We have not been told the severity of the problem of doctors prescribing drugs that give them a better profit, rather than ones that are cheaper but just as good. However, I suspect that the problem has been exaggerated and those who levy such criticisms are a minority, who can easily go to another doctor.

      Let me first say that the move is discriminatory against general practitioners and private doctors. If the move is in response to criticisms about doctors making money from selling drugs, then it should extend not just to individual doctors, but also to medical groups and hospitals as well because it is also possible that doctors in such entities will be influenced by considerations of their employer's profitability as this will ultimately have a bearing on their bonus and promotion prospects.

      One has to be reasonably pragmatic. I do not think that a doctor who repeatedly prescribes medicine not stocked by his employer because 'they are cheaper but just as good' would do very well in his career. There should also be safeguards to prevent medical groups and hospitals circumventing the restriction by setting up another company to sell medicine.

      More importantly, unless MOH expects doctors to take a pay cut (which will not happen because doctors are highly trained professionals who can easily move abroad in order to maintain their standard of living), it is inevitable that the move will result in higher consultation fees and inefficiencies, no matter how MOH phases in the change.

      With the change, instead of paying for one set of overheads at my doctor's clinic, I will now have to pay for two - the clinic and the pharmacy's, and incur additional transport expenses to boot.

      Personally, I see nothing wrong with doctors earning some extra income from selling medicine that they prescribe. Apart from keeping consultation fees down, I see it as a value-added service. When I am ill, the last thing I want after visiting my GP is to have to go somewhere else to get my medicine. This is no joke if you are taking your sick aged parent or bawling feverish child for a consultation.

      So what if I pay my family doctor a few bucks more? If I don't, I probably would have to spend it on transport for the extra trip to the pharmacy.

      The argument put forth by the Director of Medical Services, Professor K. Satku - that Singaporeans need to learn that they should have some medicine at home - seems to fly against the repeated admonitions about the dangers of self-medication.

      Am I supposed to know the difference between the medicine I have at home and the ones my doctor prescribes? And how does stocking up on medication that will likely expire before I get to use them lower my overall costs?

      We should not follow blindly US or Australian medical practice. Let us not forget that the cost of medical care in those places is among the highest in the world.

    Cheung Phei Chiet
    Forum, The Straits Times
    5 Jan 2005

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    Give patients option of buying from pharmacies

       I WAS disappointed that the Director of Medical Services did not cite any respectable study to support his claim that banning doctors from selling medication could lower health-care costs. My understanding is that, among health economists, the jury on this issue is still out. I believe there has been no comparative multinational study on this issue that could offer useful policy insight.

      Whatever studies there are have been carried out mostly in the United States and Britain, which are specific to their health-care systems, with little cross-border implications.

      However, in terms of health outcome (as measured by life expectancy and infant mortality) against per capita health-care expenditure, many countries that ban doctors from selling drugs (e.g. the US, Britain) have fared worse than countries that do not (e.g. Japan, Singapore).

      It is unwise for the Ministry of Health (MOH) to propose such a dramatic shift in policy without any proper theoretical or empirical investigation.

      To partly address the concerns raised by the Director of Medical Services, MOH could strongly mandate doctors to give clear and unambiguous advice to patients that they have the option of buying medication from pharmacies.

      This way, patients can decide for themselves whether to adhere to the current practice, or pay more for consultation and buy their medication elsewhere.

    Cheng Shoong Tat
    Forum, The Straits Times
    5 Jan 2005

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    Don't change present win-win situation

       I REFER to the article, 'MOH to stop docs from selling drugs' (ST, Jan 1). The Ministry of Health made the assumption that doctors prescribe proprietary drugs which give them better profits, instead of generic medicine which are cheaper but just as good.

      From clinical experience, there are variances in efficacy between generics and proprietary drugs, and even among generics. This could be due to quality control and carrier molecules which affect the penetration of the drug. Whether a generic or proprietary drug is chosen depends on the nature and severity of a patient's illness, efficacy of the drug and the patient's financial situation. A doctor is in the best position to balance these factors when he makes a prescription.

      When a doctor dispenses directly, he also takes responsibility for any side-effects, allergies or complications.

      Singapore has evolved its own flexible system of healthcare, providing high standards on par with developed countries, yet at only a fraction of their costs. The primary health-care setting has clinics within walking distance of every home, with one-stop facilities and long operating hours. Profiteering is kept at bay by guidelines from the Singapore Medical Council as well as by keen competition.

      In the present system, a patient can choose to obtain medicine directly from the doctor, or to pay only for consultation and get a prescription to buy from the pharmacy. This flexible system also allows doctors to waive charges for both consultation and medication to help the needy.

      This, I feel, is the ideal win-win situation for Singapore. A person who is ill, after seeing his doctor at 9pm, can get his medication, go home straightaway and rest. This is what many Singaporeans and foreigners praise us for - convenience and efficiency at reasonable prices.

      Following developed countries may not always be best. Just look at the high litigation rates, practice of defensive medicine, steep medical insurance and expensive medical consultations in the West.

      With our system, we have taken one step forward, ahead of the developed countries. Let us not undo that step.

    Dr Lawrence Cheah Kok Seng
    Forum, The Straits Times
    5 Jan 2005

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    Split of drug prescribing, dispensing not likely soon

       I REFER to the article 'MOH to stop docs from selling drugs' (ST, Jan 1) and various letters in the ST Forum page in response to it.

      The article did not communicate my vision accurately and in the right context. During the interview, I had stated that the separation of drug prescribing and dispensing will not happen soon in Singapore. I have since sent a letter to all medical practitioners on Jan 3 to clarify this.

      I have taken note of the views expressed by the public and professionals and we will study each of them. As is our practice for all major policy changes, MOH will actively engage doctors and the public in a consultative process before embarking on any changes.

    Professor K. Satku
    Director of Medical Services
    Ministry of Health
    7 Jan 2005

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    Dispensing with dispensing doctors?
    Docs not swallowing the bitter pill

       A move to separate consultation from the sale of medicine among doctors is causing a hue and cry in the profession. Health Correspondent Salma Khalik examines the pros and cons.

       YOU see a doctor for a bad cough. He gives you some medicine which you take faithfully. But the cough remains. You see him again and he gives you stronger medicine. This time, you get well.

      This is a fairly common scenario. If you question the doctor on why he didn't give you the stronger medicine in the first place, he'll probably tell you that he had hoped the milder cure would work, as stronger drugs have more side effects.

      He's probably correct. But studies have shown that this is a fairly common occurrence with dispensing doctors; that is, doctors who both prescribe and sell you the medicine. A widely-quoted study carried out in Zimbabwe found that dispensing doctors were 2.5 times more likely to prescribe 'sub-curative dosages' or medicine that was not strong enough to treat the problem. Such doctors also 'prescribed significantly higher amounts of medicines, injections, antibiotics, mixtures, cough preparations and analgesics per patient than non-dispensing doctors'.

      Similarly, a World Health Organisation paper on Policy Perspectives on Medicines listed 'perverse financial incentives' as one reason why 'worldwide more than 50 per cent of all medicines are prescribed, dispensed or sold inappropriately'. It found that 'prescribers who earn money from the sale of medicines prescribe more medicines, and more expensive medicines, than prescribers who do not'.

      This is one reason most developed countries, with the notable exception of Japan, separate consultation from dispensing of medicine, as this removes any possible conflict of interest, such as a doctor prescribing a drug that earns him a hefty profit.

      There are other tangible benefits in doctors not selling the medicine they prescribe to patients. It protects patients against unscrupulous doctors, like those at the notorious Grace Polyclinic chain who may have made sleeping pill addicts out of patients, all for a quick buck. Among them, they had dispensed hundreds of thousands of pills to at least a couple of hundred patients and profiting up to $10 for each pill.

      By getting their medicine from a pharmacist, patients would also get added protection, with a more thorough explanation of the effects of the medicine and how they should be taken. Often, patients fear wasting a doctor's time by asking what they perceive as 'silly' questions. But these may be important, and the receptionist who dispenses the medicine at a clinic is neither a trained doctor nor pharmacist.

      THERE is also a tendency for prescribing doctors to offer patients only what they have in stock. Some clinics may stock a wide range of medication. Others may have only a few types.

    The repercussions

      Despite these obvious weaknesses, the Health Ministry's plan to stop doctors from selling medicine has sparked a howl in medical circles.

      Never mind that Professor K. Satku, the director of medical services, is talking of long-term plans or that he has promised to take in views from all parties or that such a scheme will be gradually phased in.

      Doctors see it as an attack on them and their income.

      Patients too oppose it, complaining of the inconvenience of having to go elsewhere to pick up their medicine. Even the assurance that such a move will see pharmacies popping up at every neighbourhood seems unlikely to sway them.

      But all this is likely to be moot. The strong doctor lobby here looks set to kill the move even before the idea can be fleshed out. The close to 3,000 doctors in private practice are not about to give up a major source of income.

      General practitioners (GPs) in particular depend significantly on the sale of medicine to augment their income. They will argue that without this source, they will need to raise consultation fees.

      Since their money comes from patients, it's inevitable that they will find another way to get it. And who can fault them? No one is out there doing a job for altruistic reasons.

      Patients may also end up paying more as both the clinic and the pharmacy need to make a profit. So separating the prescription from the sale could add another layer of cost.

      A GP who said the market is highly competitive, with patients voting with their feet, is not exaggerating. Some GPs have shaved so much from their consultation that they have become essentially medicine sellers with a licence to prescribe.

      Prof Satku may find his proposed move politically untenable.

      To make matters worse, only small players will be affected. Dr Goh Jin Hian, executive director of the Parkway Shenton clinic chain, has said that his company would simply set up a parallel chain of pharmacies. It will mean a little more paper work, but the money goes into the same pocket. GPs in the chain, knowing that patients would just go next door to the pharmacy owned by the same company, will carry on prescribing the way they do now.

      So while it may be good for patients in the long run, there are ways of gaming the system that would make a mockery of the suggested change.

      A compromise, however, may be possible. Let GPs continue dispensing medicine but bar them from doing so with certain addictive drugs such as sleeping pills, which they can prescribe but not dispense.

      Better to introduce the change among the specialists, the doctors who make the big, big bucks. Most GPs make between $10,000 and $20,000 a month. A specialist in private practice easily earns four times that, with top earners raking in more than $300,000 a month. Over-prescription or the prescription of more expensive medicine is more likely to occur at this level of treatment.

      Medicines that specialists prescribe, due to the type of illnesses they see, are generally more expensive than the run-of-mill cures from a GP for acute problems, so this is where the problem, if any, lies. Some private specialists, as a matter of course, charge $1 more per pill compared with public hospitals for unsubsidised drugs. Sometimes, the difference is much greater. Consultation fees are also higher, as the competition at this level is less intense. Specialists will remain well-off, even if they lose the profit they now make from the sale of medicine.

    On the patient level

      THE inconvenience to patients is minimal as many specialists operate in medical centres which also house one or more pharmacies. Patients rarely consult a specialist in his clinic for an acute illness, so the problem of a very sick patient needing medicine urgently is almost non-existent. They are there for chronic, serious or complex medical problems. They are the ones who will benefit most from having their medication, and its possible side-effects, carefully explained by a pharmacist.

      Yet another advantage is that when the patient sees several specialists for a range of illnesses, a pharmacist can keep tabs of the different medicines and alert both patient and doctor should there be any conflict. There are also more small groups and solo practices among specialists, so they won't be able to circumvent the change the way GP groups can.

      But separating consultation from the sale of medicine may not do much to curtail rising health-care costs unless the ministry inserts a system of checks to ensure that pharmacies do not take over where doctors leave off; that is, sell more expensive alternatives, or branded rather than generic medicine to patients for larger profit.

      One suggestion by WHO is for pharmacies to charge a flat dispensing fee, regardless of the price of the medicine which is sold at cost. While this may raise the cost of cheap medicine, it will reduce significantly the cost of pricey ones.

      In some places, pharmacists have to offer patients cheaper alternatives if they exist. The Government may also need to set up its own pharmacies to offer cheap medicine, or as is done in Australia, control the prices of essential medicine at commercial pharmacies.

      The ministry must also ensure that pharmacies do not offer kick-backs to doctors who prescribe more expensive medication. This won't stop pharmaceutical companies from influencing doctors to prescribe their brand of medicine, but it is not a new situation.

      So, by confining the change to specialists only, Prof Satku would stand a better chance of pushing it through, for the benefit of patients in the long run. It would be a pity if the ministry knuckles under the demands from self-serving doctors and drops the idea altogether.

    Salma Khalik
    The Straits Times
    9 Jan 2005

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    No lobby against split of prescription, dispensing
    Singapore Medical Association

       THERE has recently been debate in The Straits Times about the benefits of separating prescription by doctors, from dispensing of medicine from their clinics.

      Doctors in Singapore have heard two differing accounts of the intention of the Ministry of Health (MOH) on this matter - one reported in ST and another from circulated MOH minutes of the meeting - and most have no doubt as to which of these is accurate.

      We had hoped that there would be no need to speak further on this matter publicly, especially as the Director of Medical Services, Professor K. Satku, had written to the ST Forum ('Split of drug prescribing, dispensing not likely soon'; ST, Jan 7) to say: 'The (ST, Jan 1) article did not communicate my vision accurately and in the right context. During the interview, I had stated that the separation of drug prescribing and dispensing will not happen soon in Singapore.'

      However, The Sunday Times published a one-page article on the topic only two days later ('Docs not swallowing the bitter pill'; Jan 9). This included generalisations and comments that Singapore Medical Association (SMA) members, and indeed some of our patients, have found offensive. Therefore, for the sake of clarity, the SMA wishes to state the following:

      The opening paragraphs of the article speak of local patients not getting better until at least the second visit to the doctor and then goes on to quote a study carried out in Zimbabwe that found that 'dispensing doctors were 2.5 times more likely to prescribe 'sub-curative dosages' of medicine that was not strong enough to treat the problem'. Because the first paragraphs were written to the reader ('You see a doctor... you see him again... you get well'), we can only conclude that your health correspondent is alleging that readers with similar experiences in Singapore have also suffered from sub-curative dosages prescribed by doctors, deliberately and for profit.

      This is a very serious allegation of misconduct against a profession. May we request your correspondent to provide us, or the statutory authority, with adequate details for further verification. Doing so will prevent a misunderstanding that this allegation about widespread professional misconduct in Singapore has a factual basis.

      The article also states that the idea of separating prescription from dispensing is unlikely to happen, because 'the strong doctor lobby here looks set to kill the move even before the idea can be fleshed out'.

      The SMA would like to state categorically that we have not lobbied the MOH on this matter. We also verified on Monday that the MOH has not been lobbied by any other group of doctors on this issue.

      On the contrary, all patients in Singapore have always been able to ask their doctors for a prescription that allows them to get their medicine from an independent pharmacy - the precise thing that your health correspondent is asking for.

      They have always been able to, and many of our patients actually do. On both those counts, therefore, we believe your health correspondent is factually wrong.

      Finally, your health correspondent concludes that 'it would be a pity if the ministry knuckles under the demands from self-serving doctors and drops the idea altogether'.

      By 'self-serving doctors', we can only assume that she is referring to the 'strong doctor lobby here', which she has earlier characterised as '3,000 doctors in private practice'.

      As stated above, the SMA has neither lobbied nor presented demands to the ministry on this matter, nor is it or MOH aware of any other group of doctors that has done so.

      Because there is no basis for the adjective she has chosen, we hope your readers will understand why the SMA finds that her tarring all doctors with the same brush as 'self-serving' is extremely offensive.

    Dr Lee Pheng Soon
    President
    Singapore Medical Association
    13 Jan 05

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    10 Questions Hobbit Would Like to Ask Ms Salma Khalik

       The recent articles by Ms Salma Khalik: “Doctors not swallowing the bitter pill” and “MOH to stop docs from selling drugs” on 9 and 1 January 2005 respectively are articles of the same high standards as we have learned to expect from her.

      But let us do something new for a change. Instead of Ms Salma Khalik always doing the questioning as a reporter, Hobbit would like to turn the tables a bit and ask her some questions.

    1. Where are “the plans” and a 3000-strong doctor lobby that can influence government?

      Ms Salma Khalik claimed that there is an impending and definite, albeit long-term, move by the Ministry of Health (MOH) to remove dispensing rights from doctors. Furthermore, she implies that an effective lobby of 3000 private practice doctors exists in Singapore: “The strong doctor lobby here looks set to kill the move even before the idea can be fleshed out.”

      Firstly, no such lobby exists in Singapore. Secondly, even if it did, it cannot be effective. The suggestion that the Singapore government yield to a lobby of 3000 private practice doctors against what the government views to be in the best interests of Singaporeans is just deliriously preposterous.

      Just like the world is still waiting for America to discover “Weapons of Mass Destruction” in Iraq, we would like to ask Ms Salma Khalik: “Where are ‘the plans’ you keep talking about?” and “Do you have documentary evidence of these plans, for example, some MOH paper detailing these ‘plans’ or at least discussing separation?”

      More importantly, where is the proof that a lobby, and an effective lobby at that, exists that can scuttle MOH’s plans?

    2. How did Ms Salma Khalik interpret DMS’ words?

      In direct response to Ms Salma Khalik’s article on 1 January 2005, the Director of Medical Services (DMS), Prof K Satkunanantham took the unprecedented move to circulate the minutes of the 1 December 2004 meeting between Ms Salma Khalik and himself to ALL doctors. The proceedings of the meeting were to have been the basis for her reporting.

      This move by the Ministry is highly significant and represents more than an oblique lament that she had grossly mis-communicated the proceedings of the meeting. The laxity in the interpretation that she practised was sufficient to trigger such an official profession-wide clarification. The official minutes of the meeting recorded six items brought up during the interview by Ms Salma Khalik. Item 5 concerned drug dispensing.The Hobbit reproduces this item here in its entirety: “On the separation of drug dispensing from the practitioner as in developed countries, DMS said that it would not happen soon in Singapore. It would take some time before doctors in Singapore appreciate the benefits that such a system would bring to their practice.”

      In the cover note to the minutes, the DMS further clarifies: “From the Ministry’s perspective, the item (5) is not of immediate concern. I do not wish to be drawn into a debate with the press and lose our focus...that is why I have decided to write to you directly to explain our position.” He adds as a closing remark: “I will strive to mend any damage done to our trust so that we can work together to serve our patients better.”

      It is therefore plain to see that the reporting by Ms Salma Khalik was so pernicious in nature that trust between the Ministry of Health and the medical profession could be eroded. Does “it will not happen soon” equate to “it will definitely happen in the future”? She writes on 1 January 2005: “Singapore is slowly moving towards separating a consultation with a physician from his selling the medicine he prescribes.” In an email dated 30 December 2004 to several leaders in the medical profession asking for their opinions, she claims: “Singapore is moving towards separating consultation from the sale of drugs – the way it is done in most developed countries – but that the move will be gradual, as it affects doctors’ rice bowl. But separation will come.” On 9 January 2005, she further writes: “A move to separate consultation....” and “the Health Ministry’s plan to stop doctors from selling medicine”. To the reasonable student of English, the words in italics denote something definitive and impending when it is clear from the Ministry’s correspondence that nothing firm is on the cards. By what rules of the English language did she interpret the DMS’ words to such an outcome?

    3. Who has primacy in Singapore in determining the agenda – Singapore’s government or the reporter?

      The Hobbit would like to add that four of the other five points in the minutes released by MOH received longer recordings in the minutes than item 5. Yet, Ms Salma Khalik has chosen to only talk about what was a minor subject discussed during the meeting in her 1 January 2005 report. She has ignored the other five items that were discussed during the meeting in MOH. We can only surmise that item 5 was the only thing on her agenda while all the others were not.

      The Hobbit is a great fan of our Minister Mentor, and she would like to draw Ms Salma Khalik’s attention to what Minister Mentor said: “Freedom of the press, freedom of the news media, must be subordinated to the overriding needs of Singapore, and the primacy of purpose of an elected government.” (From Third World to First – Memoirs of Lee Kuan Yew, page 218.)

      However, as we can see from her articles in The Straits Times on 1 and 9 January 2005, by choosing to only highlight one item to report on (and out of context as well), and deliberately ignoring the other five, she had chosen what to report and how to report with scant respect for the government’s agenda. So Hobbit’s question to Ms Salma Khalik is: “Who has primacy in dictating the agenda for healthcare in Singapore, Ms Salma Khalik or the Ministry of Health?”

    4. Why Zimbabwe?

       Ms Salma Khalik has also seen it fit to apply studies conducted by Danish pharmacists on Zimbabwe to Singapore. What are the similarities between Zimbabwe and Singapore? An experienced health journalist like her would surely know that health economics and policy research is largely based on local demographics as well as socio-economics and political factors. Unlike clinical and scientific research, conclusions reached in health economics and policy research cannot be easily applied across cultures, governments and countries. For the avoidance of doubt, the Hobbit will offer her as well as SMA News readers some facts about Zimbabwe and Singapore, to illustrate the relevancy of the journalism that Ms Salma Khalik is dishing out to The Straits Times readers.

    (From World in Figures, published by The Economist, 2004 Edition.)
    ParameterSingaporeZimbabwe
    Area 639 sq km 390, 759 sq km
    Population (millions)4.1 12.9
    Human development index 88.5 54.8
    GDP per head (US$) 20,850 700
    Health spending, % of GDP 3.3 7.3
    Life expectancy:
      Men
      Women

    75.9 years
    80.3 years

    33.7 years
    32.6 years
    Doctor per 1000 population 1.4 0.1
    Hospital beds per 1000 population 3.6 0.5
    Computers per 100 household 50.8 1.2
    Annual average % increase
       in real GDP, 1991 – 2001
    6.9 0.1
    Corruption perception:
      Index
      World ranking

    9.3
    5

    2.7
    71

    So Hobbit asks Ms Salma Khalik: “Why Zimbabwe? The later article by her colleague, (Dr) Andy Ho, quoted solid examples from Korea, Taiwan and Japan, places that are more akin to Singapore in terms of culture, economic development and quality of medical services. The Hobbit has faith that The Straits Times reader should have no problems in seeing which examples are more relevant.

    5. Why generalise?

       Ms Salma Khalik likes to quote the case of Grace Polyclinic, which included a handful of unethical doctors (already dealt with by the Singapore Medical Council). From there, she generalises that dispensing rights should be removed from the whole profession to protect all patients in Singapore. This is an unnecessary generalisation. Stereotyping and generalising can be very painful experiences for the vast majority who do not fall under the original criteria or description.

      To illustrate the point, Hobbit would like to ask Ms Salma Khalik: “Does it mean that just because one family member has been convicted for drunk driving and banned from driving, we ban the whole family from driving? If not, why generalise?”

    6.Why target private sector specialists now when the whole story started with a few rogue GPs prescribing addictive drugs indiscriminately? Just because they earn more money or because Ms Salma Khalik has extensive evidence that private sector specialists also prescribe addictive drugs indiscriminately?”

       We will now move into the main thrust of Ms Salma Khalik’s arguments. The original premise for her alacrity to support a call for separation is to deny doctors the opportunity to earn money from dispensing. She supported this with the case of the GPs of Grace Polyclinic. She now confesses that she is alone in this cause because the patient of the GP will not accept the complicated logistical requirements that go with separation, not to mention the probable additional costs. She then proposed that barring GPs from dispensing addictive drugs would suffice since they make between “$10,000 and $20,000 a month”. Instead, the authorities should now train their guns on the specialists in private practice, those who “easily earns four times that, with top earners raking in more than $300,000 a month”.

      The Hobbit is quite confused at this turn of events. What was started off by Ms Salma Khalik as an act to protect the patient from unscrupulous GPs profiteering, turned into protecting them from GPs prescribing addictive drugs, and has now turned into a crusade against the high-earning specialists. We are confused because specialists have not been known to prescribe drugs, whether addictive or otherwise, indiscriminately, and the real high-earning specialists make most of their money from procedure fees, not drugs.

      So, are we targeting these specialists who “make the big, big bucks” because they prescribe indiscriminately, or because “heck, we just don’t like them earning so much, whether they earn it ethically or not”?

    7. How come patients of private specialists do not get medicines from pharmacies when they are a few steps away?

       It is also interesting to note that these so-called specialists that earn “big, big bucks” work in private hospitals with large well-stocked hospital pharmacies. Patients can easily walk a few steps to these pharmacies and get their prescriptions filled, but the majority of them do not. Why is this so?

    8. Why the double standards?

       We go back to the centre of healthcare – the patient. The centre of healthcare is not what the doctor wants to do or what Ms Salma Khalik feels is best. Today’s system affords liberty of choice to every patient. Every patient exercises his choice to use the dispensing channel that he feels is best for him. This is supported by the principle of patient autonomy. What she is proposing is the removal of patient autonomy – the right of the patient to choose. While she is comfortable in exercising considerable liberty in the interpretation and reporting of what actually transpired between her and Ministry of Health, she is at the same time quite bent on restricting a patient’s liberty of choice.

      The Hobbit finds this double standard on her part quite simply disturbing and asks her: “Why the double standards, Ms Salma Khalik?”

    9. Who’s against whom?

       Back to the case put forth by Ms Salma Khalik. The letters written by lay persons and one doctor, which were published in The Straits Times Forum on 5 January 2005, quietly suggest that Ms Salma Khalik’s call for separation has not received much traction. Even she admits it is going to be tough as it may be “politically untenable” and “patients too oppose it”. Perhaps it is not a case of the government (“knuckling under pressure”) against the “self-serving” medical profession (“attack against their income”), or tension between the people and the government (patients against the government’s plan for separation as even “assurance that such a move will see pharmacies popping up at every neighbourhood seems unlikely to sway them”). Could it be that the main reason that her ideas have had little purchase on the mindshare of others is that the ideas do not serve the best interests of real stakeholders in the issue: the patients, the government, and to a far lesser extent, the paltry 3000 private practice doctors, and all the three parties have collectively aligned interests to keep the status quo? So who is against whom here?

    10. Does Ms Salma Khalik fill her prescriptions at pharmacies?

      The real crunch question, ma’am. It may seem highly personal and not appropriate to be tabled before all SMA members. But since you made this a public issue first, it is only fair comment that the Hobbit asks you to let the folks out there know whether you practise what you preach (or the minimum: you definitely intend to practise what you now so strongly advocate).

      We can only speculate. But it is a reasonable speculation that even Ms Salma Khalik falls ill from time to time, and she also consults a GP. So, does she take the prescription from her GP and go to get it filled at the pharmacy and not at the clinic? Will she permit her GP clinic to examine their records and publicly confirm that she has not collected her medicines at the clinic? If she indeed gets her prescriptions filled at pharmacies, kudos to her and the Hobbit salutes her unreservedly. If not, then, why not?

      Even if she has been taking medicines from the in-house dispensary from the past, we doctors are a forgiving lot – so we forgive her. But going forward, she should at least give a public undertaking that she will only get her prescriptions filled at a pharmacy from henceforth.

      After all, Ms Salma Khalik, if separation of dispensing from prescription rights is such a great idea, should you not stand up and be counted right away, and start the ball rolling at the personal level?

    The Hobbit
    SMA News Volume 37, Issue 01
    January 2005

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    Letter from DMS (MOH) to all doctors

    MH 84:01/1-36 
    
    3 January 2005 
    
    Dear Doctor, 
    
    I refer to the article entitled “MOH to stop docs from selling drugs” in the Straits Times on 
    1 Jan 2005. 
    
    I enclose the notes of the meeting between Salma and myself as recorded by an 
    executive staff of MOH for your information and assurance of our intention. 
    
    Point 5 in the notes is the item referred to in the Straits Times article. As you can see 
    from the Ministry's perspective the item is not of immediate concern at all. 
    
    I do not wish to be drawn into a debate with the press and lose our focus. We have more 
    pressing items to see to in particular the Disease Management Programmes to roll out. 
    That is why I have decided to write to you directly to explain our position. 
    
    I would also like to draw your attention to Para 2 of the notes of the interview. Please be 
    assured that although in the Ministry we are studying various models of healthcare we 
    believe in a consultative process with you before finalizing any changes. 
    
    I regret that this issue has been so abruptly brought to your attention. I hope to introduce 
    many changes with your support and cooperation. 
    
    I will strive to mend any damage done to our trust so that we can work together to serve 
    our patients better. 
    
    With Best Wishes for 2005. 
    
    Yours sincerely 
    
    PROF K SATKU 
    DIRECTOR OF MEDICAL SERVICES 
    
    


    Notes on DMS' interview with Salma Khalik from Straits Times.

    Salma met with DMS at MOH on the 1 Dec 2004, at 3.30pm.

    The interview was on the GP profession. Some GPs have told Salma that they are seeing fewer patients now. Salma asked whether there was an abundance of GPs in Singapore and if so, why the increase in medical graduates. DMS explained that the provision of primary care must continue to grow and must always be improving as our aging population increases. He also explained that he hopes for better-trained GPs either through years of practice or studies so that they are confident enough to provide patients with preventive care such as advice on early detection and opportunistic screening. The aim is to have GPs providing more holistic care to people in the neighbourhood, instead of sending them to a specialist each time they feel that their patient needs extra care.

    DMS informed that he would be gradually putting forward the following changes. He also informed that all changes would go through various stages of consultation with medical practitioners and would be implemented over a period of time. The changes include:

    1. Implementing the Family Physicians Register within the next 2-3 years. To qualify, GPs would have to meet certain Diploma requirements to enable more holistic patient care and treatment. DMS explained that it is not the aim of the Ministry for every GP in practice to obtain the diploma but for those who wish, they could try to obtain the necessary qualifications.

    2. Rolling out various major disease management programmes very soon.

    3. Starting from the next financial year, the clusters will go on a ‘block budget' where they are given a fixed subsidy amount to take care of subsidised patients while maintaining a level of care as determined by MOH. He also explained that if the hospital did not meet that level of care, he would take the hospital to task. He emphasized that hospitals should not compromise the level of care or neglect their main focus which is to take care of subsidised patients.

    4. Increasing progressively the number of over-the-counter drugs in Singapore, especially those already available in countries such as Australia, US & UK. He explained that it would be difficult to answer to the public on why there is a need for the drug to be prescribed if in other developed countries, it is available over the counter. Unless HSA is able to provide a valid reason for disallowing it, DMS felt that these drugs should be allowed to be sold over the counter. In response to why is it timely to empower Singaporeans, DMS said that Singaporean are now more informed and better educated and are able to take better care of themselves.

    On whether we would allow drug manufacturers to advertise, DMS said that this is not the right time yet. As there are too many brands of drugs for the same use in the market, he felt that Singaporeans might not be able to determine what is best for them and such advice should be left to the doctor who is caring for the patient. DMS felt that to allow manufacturers to advertise would only confuse the public and encourage them to spend money on “branded” drugs which might not suit their needs or financial circumstances for the slight increase in benefit.

    5. On the separation of drug dispensing from the practitioner as in developed countries, DMS said that it would not happen soon in Singapore. It would take some time before doctors in Singapore appreciate the benefits that such a system would bring to their practice. (Highlights mine:Gerald)

    6 DMS also shared his vision for the following.

    i) GPs working in close proximity to form functional groups where they can work together to have better purchasing power and to take care of each other's patients if one is away from the clinic.

    ii) Extending Primary Care Partnership Scheme to include handicaps in the near future.

    iii) More GPs offering to teach / train medical students - giving the students opportunity to learn from them and to acquire medical knowledge not taught in text books.

    The interview ended at 4.30pm.

    Salma informed that the story would most likely take on the angle of an “interview with DMS and his vision for healthcare in Singapore”. The date of publication is to be confirmed.

    Nikole, CCD




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    Liberalise distribution of prescriptive drugs
    Letter to Straits Time Forum

       THE letter, 'High prices for common drugs in HDB heartland' (ST, Feb 21), by Madam Gan Siok Wah clearly shows the price of medicine in Singapore can be exorbitant.

      A member of my family was charged more than $40 by a doctor just for a small rash, but the medicine proved totally ineffective. In all, the person spent over $100 with various doctors without success. Instead, the rash was later cured quickly and effectively with a $6 non- prescriptive ointment from a pharmacy which was recommended by the attendant pharmacist.

      One way to counter high prices of medical care is to liberalise the distribution of prescriptive medicine via pharmacies. I have already petitioned the Government on this. Other countries that are more advanced medically have done this, so why not Singapore?

      Furthermore, university-trained pharmacists are well-versed in the use of prescription medicine so why are they not allowed to dispense them via pharmacies? In the current situation, the pharmacist may need a prescription from the doctor just to use a prescriptive medicine on himself.

    .
    .
    .

      I therefore suggest that the Government liberalise the distribution of prescriptive Western medicine via pharmacies and give legal recognition to MCs issued by pharmacists and certified physicians.

      I believe the cost of Western medicine has driven some people in other countries to buy them via legitimate outlets on the Internet, saving them a lot of money. To give an indication, the demand for online medicine is so great that last year the Canadian government said it could not afford to jeopardise its national supply of medicine by selling it via online pharmacies.

    Chia Hern Keng
    Forum, The Straits Times
    27 Feb 06

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    Patented drugs keep medical costs high in S'pore
    Letter to Straits Time Forum

       I refer to Dr Camilla Wong's letter to itemise medical bills to reduce costs (ST, March 4).

      Assuming that Singapore follows Western countries where the doctors only see the patients and the prescriptions are dispensed separately by pharmacists, then things have to change here.

      A common problem encountered by patients who want their precriptions is the inadequate inventory of many suburban pharmacies. Imagine the frustration of consulting a doctor and then be told that no medicine is available in the pharmacy.

      I also do not understand how the costs of medical care can be lowered by separating the consultation fees and the dispensing of medicines.

      Pharmacies here dispense mainly patented drugs and keep very little of the cheaper generic medicine which can cost ten times less than the original drugs. The total costs for patients increase exponentially due to this anomaly. In fact, clinics are the ones which are helping to lower medical bills for patients by prescribing good generics.

      Yes, there may be at least 15 brands of generic clarithromycin in the market but the experience of doctors is that not all generics are the same.

      It is good that generics are now required by law to prove their bio-availablity, ie how pure and how fast the generic drugs are absorbed into the body to reach effective levels compared to the originals.

      Which is why we hear often from patients who tell us that certain generic drugs do not work as well as a branded drug that they had used.

      Unless we solve the logistical and inventory problems of the pharmacies, separating the consultation, prescription and dispensing fees will result in higher medical costs and more frustration for the patients.

    Lim Boon Hee
    Forum, The Straits Times
    16 Mar 2006

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    Let doctors diagnose and pharmacies sell drugs to lower medical costs
    Letter to Straits Time Forum

       "Patented drugs keep medical costs high in S'pore" says Dr Lim Boon Hee (ST Online Forum, March 16). I don't share this view.

      The inadequate inventory of many suburban pharmacies is due to lack of demand and not inventory problems. If every patient needs to buy his own medicine as a rule rather than an option, the supply chain will link the loop seamlessly.

      Citing conveniences for patients and that it's cheaper to prescribe and dispense medicine is purely academic and not helpful when patients are not given the free choice to purchase their own medicines at any pharmacy.

      Only through stiff competition over time will the prices find their own levels. It is through competition in quality and price that we can make Singapore a medical hub for this region. There is no advantage if we still hold on to the outdated practices which are frowned upon by the developed world.

      Dr Lim further assumes that pharmacies here dispense mainly patented drugs and keep very little of the cheaper generic medicine which can cost ten times less than the original drugs.

      In reality, there are two reasons for such a phenomenon. One, doctors don't give prescriptions to patients to buy their medicines elsewhere. Even if patients want prescriptions, the doctors will specify branded or patented drugs which will cost the same price as the clinic's because the profit margins are controlled. Second, since no generic medicines are in demand in the market, who wants to stock the best, proven and cheaper drugs in their stores?

      Unless the medical fraternity is prepared to let go its grip on prescription and dispensing, patients would have no chance to buy drugs elsewhere.

      It is not conducive to the free market situation for pharmacies to flourish and compete like mobile phones companies or home appliances.

      The Ministry of Health has done a good job in making medical treatment charges open and transparent. This causes prices to drop a lot when people are well-informed and given a choice. The private sector should follow suit to support such a policy. The list-price practice is the right way to encourage competition to reduce health care costs. It is time that free competition be introduced in the pharmacy trade to achieve real cost savings.

      Doctors can practise their diagnostic skills and prescribe the appropriate medicines for healing. Let the pharmacists practise their craft and bring in the best, cheaper and powerful generic drugs to suit the requirements or preferences of individual patients.

    Paul Chan Poh Hoi
    Forum, The Straits Times
    21 Mar 2006

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    Khaw: Docs dispensing drugs: System not without its benefits
    Minister Of Health, in Parliament

       HEALTH Minister Khaw Boon Wan is in favour of keeping the current system where doctors are also allowed to dispense medicines. But he told MPs yesterday that he would work to enhance the system. 'The key is to give our patients the choice to fill the prescriptions wherever they wish, be it at the doctor's clinic, in a private pharmacy, or even across the Causeway,' he said during yesterday's debate on the Pharmacists Registration Bill.

       Madam Halimah Yacob (Jurong GRC), who heads the Government Parliamentary Committee for Health, raised the idea of separating prescribing and dispensing of medicines - as is done in some countries. She said such a system would have pharmacists acting as a check on doctors' prescriptions, which would improve patient safety. And patient safety, she argued, was a 'greater overriding consideration' than the convenience of being able to consult a doctor and fill a prescription at one place.

       Doctors in private practice here prescribe and dispense medication; in public hospitals and polyclinics, doctors usually prescribe the drugs, while pharmacists in the same institution dispense it.

       But Mr Khaw was not in favour of leaving all dispensing of medicines only to pharmacists. Saying that the current system was 'not without its benefits', he pointed to convenience and cost savings for patients who pick up their medicine at the same place they see the doctor.

       However, he suggested that, as a start, doctors in private practice should follow the lead of public-sector clinics and hospitals and provide all patients with a clearly written or printed prescription as a matter of course. They should then leave it to the patient to pick up the medicine anywhere he wants to. If they choose to do so at the doctor's clinic, the cost of the medication should be itemised on the bill, separate from the consultation fee.

    Lee Hui Chieh
    The Straits Times
    21 Sep 2007

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    Doctors and medicines
    Straits Time Editorial

       NOT everyone will agree with Health Minister Khaw Boon Wan's view that doctors should continue to be allowed to fill as well as write prescriptions. Citing consumer choice, market maturity and patient welfare, some wonder whether Singapore should be moving towards the norm in developed societies by doing away with what they consider an outdated practice. Yet barring doctors from dispensing drugs has implications, not all of which may be of benefit to patients. The cost of a doctor's visit is most likely to increase, for at least two reasons that are not necessarily related. First, even if many physicians would not acknowledge it, they probably can charge less for consultations because they are making a good profit on the drugs they prescribe and dispense. Second, even if patients may be sceptical about it, doctors maintain they keep medicine costs down by passing on savings by buying in bulk from drug companies. They like to say they are in the best position to bargain with their suppliers.

       Whichever is the actual or bigger reason, patients are likely to see their medical bills go up if pharmacists only can fill prescriptions. Indeed, in some countries where doctors prescribe only and do not dispense, pharmacists add a professional dispensing fee to the price of drugs they sell. Requiring doctors to give patients itemised receipts and legible prescriptions will bring some transparency, but probably is still not enough to enable patients to make informed choices. How many patients in public hospitals and polyclinics, which issue printed prescriptions, go to a druggist elsewhere to buy their medicines? Cost considerations aside, again not everyone will necessarily go along with MP Halimah Yacob, even if they agree with her opinion that patient safety in having pharmacists double check doctors' prescriptions overrides the convenience of having medicines sold by the attending doctor.

       Money, time, convenience and safety - these variables interact. Clearly, whoever is to do the dispensing, only an objective study can establish where patients' interests in fact lie, particularly where market forces actually act to lower prices, what level of convenience is acceptable, and what degree of safety is optimal. For now, patients have the choice of asking their doctor for a prescription but purchasing their drugs at a pharmacy. Before patients can know for certain which approach will serve their interests best, there is no rush to separate prescribing from dispensing.

    The Straits Times
    24 Sep 2007

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    Separate drug dispensing: Educate the public first
    Chairman of the Government Parliamentary Committee for Health

       I REFER to the editorial, 'Doctors and medicines' (ST, Sept 24), on doctors prescribing and dispensing medicines. In the full text of my parliamentary speech, I had mentioned that 'in Singapore's context this (separate prescription and dispensing of medicine) cannot be done overnight as we need to educate the public' and that the first step is 'to encourage private practitioners to ensure transparency in their billings', a point supported by the Ministry of Health.

       I had also suggested that we look at Japan where it is not mandated by law but, in practice, patients are given a choice whether to have medicines dispensed by doctors or pharmacists and a significant number had opted to seek the pharmacists' services.

       Doctors and pharmacists in our public hospitals and polyclinics complement each other in the management of drug therapy. To quote Health Minister Khaw Boon Wan, pharmacists provide the 'checks and balance in the medication use process - from doctor's prescription to drug administration', which is not the case for private general practitioners (GPs).

       A first small step would be to encourage GPs to separate prescriptions so that patients have a choice and this should be done automatically without the patient having to ask for it.

       Recently, a friend of mine visited a GP for a simple flu and was charged $80. When he asked why the bill was so high, he was told that it was because he had been prescribed a very expensive but very potent antibiotic which cost $50. I wonder whether we need such a potent antibiotic for a simple flu and also who could provide the check.

       I agree that we need to study the idea and require more efforts to educate the public but it is something worth considering. We should not presume that if market forces are allowed free rein, patients would have to pay more if they are given a choice.

    Halimah Yacob (Mdm)
    MP for Jurong GRC
    The Straits Times
    26 Sep 2007

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    Making Doctors Stop Dispensing
    Tough pill to swallow

       THE spring allergy I suddenly developed a few years ago after living in New York for nearly two decades stung my eyes, made my nose run and scratched my throat as though I was in a tear gas attack, but it was the price of the nationally advertised brand-name anti-histamines my doctor prescribed for it that almost made me cry.

       The pharmacy charged me more than US$120 (S$180) for 24 little tablets. A year later, after the federal drugs administration allowed people to buy the pink pills without a prescription, the price fell to US$10.95. Same quantity, same potency.

       Big pharma probably took its big cut when the drug first hit the market, justifying it by the supposedly huge research and development cost it always claims it has to bear. The pharmacist also probably drove up the price, figuring that the burden falls not on the patient but on the health insurance company which nevertheless passed it on to me in the form of higher premiums.

       As in many developed countries, physicians in the United States do not dispense the medication they prescribe. Would the price have been different if they did? Maybe, maybe not.

       All I knew then was that the price was not going to be any lower at the pharmacy down the road than at the pharmacy in the hospital where my doctor had his practice. Some pharmacists also tack on a professional dispensing fee of a few dollars to the medication cost.

       Singaporeans who think their medical bills will not rise or may even fall if pharmacists take over dispensing from doctors would be in for some bitter medicine. Health Minister Khaw Boon Wan favours allowing doctors to continue dispensing, pointing out last week that this is not without its benefits.

       One of those benefits is that general practitioners (GPs) can lower their consultation fee, balancing it with the profit they make on medicine. It is an open secret that GPs make a profit on drugs. They observe that patients are more willing to pay for medicine than for their counselling and advice, which ironically may help cure their illness more effectively than the medication can.

       For years, GPs were unable to charge more for consultation because Singapore Medical Association guidelines capped their fees and because polyclinic competition kept rates low. With the SMA fee list discontinued, they may be able to charge more, but even if they then charge less for medication, it would still be cold comfort to patients.

       Doctors in HDB estates point out that polyclinics are not their only competitors. They have to bid against coffee shops, retailers and other businesses when renting their premises. The SMA could perhaps conduct a survey on GPs' income which, according to some, has dropped in recent years, even though many of them, especially those in single-practitioner clinics, work long hours and full weekends.

       Another benefit if dispensing remains with doctors is convenience: Patients do not have to go somewhere else to buy their medicine. Some have complained that in hospitals, they have to queue to see the doctor, then go to the pharmacy and join another line to wait for their medicine. Sick people want the pharmacy to be no farther than nearby, preferably within the clinic. They just want to see the doctor, collect their medicine and go home and rest.

       Member of Parliament Halimah Yacob, who heads the Government Parliamentary Committee for Health, has said it would improve patient welfare to have pharmacists double-check doctors' prescriptions, arguing that safety overrides convenience. It would be helpful to see data from other countries on the frequency of physicians' prescription errors that pharmacists manage to catch. Some doctors maintain that having two different people prescribing and dispensing may not be advisable. They say the dispenser may not understand why the prescriber has chosen a particular drug.

       She dispenses from textbook knowledge, not knowledge of the patient, unless she also assesses the patient, which would then add to the waiting time, or she has to call the prescriber to comprehend the case better.

       Apart from safety, some also mention consumer choice and market maturity as reasons for Singapore to keep up with developed countries and dispense with what they regard as an outdated system. But patients here do have a choice. They can ask their doctor for a prescription for a pharmacist to fill, although it might be awkward to insist on one, given the often delicate doctor-patient relationship.

       It is the same awkwardness that those opting out face in an opt-out scheme such as CPF-outsourced Eldershield insurance, except perhaps more so, given the up-close and personal situation.

       Mr Khaw's suggestion that doctors should, without demand, issue prescriptions that may be filled elsewhere, should help avoid such unease. Some GPs already give patients printed prescriptions and itemised receipts.

       As for market maturity, it may be no more than globalisation that is bringing change. This reinforces market dynamics rather than constrains or abolishes them. Patients would have to weigh carefully how their interests are best served, including how market forces could act with the greatest impact to lower or contain prices. To decide whether it is advantageous to them for doctors or for pharmacists to dispense medicine, they need comparative data. Perhaps the Health Ministry could provide this in a timely and comprehensive way to help them make an informed choice.

       It is probably true that pharmacists are better trained than GPs to dispense. Nevertheless, a good GP familiar with her drugs can do just as well. It is also true that it is often a clinic assistant instead of the doctor who actually dispenses, but such assistants do receive some training, in fact, by pharmacists.

       Many of the 1,468 registered pharmacists here work in manufacturing, wholesale and marketing, seldom coming into contact with individual patients. Their role will likely expand. New statutory measures will enhance their professionalism, such as compulsory continuing education and a specialist registry.

       They will need to keep abreast of knowledge, build expertise to cope with accelerating development, increasing complexity and proliferation of new pharmaceuticals, promote optimal drug use, and advise on drug safety, adverse interaction and side effects. If doctors were to give up dispensing entirely, more pharmacists will be needed. The National University of Singapore has nearly tripled its enrolment of pharmacy students to 115 over the past 10 years, but there is a need for 200 more a year for the next decade.

     
    KNOCK-ON EFFECT

      Patients would have to pay pharmacists to dispense.
      GPs, unable to compensate by charging a margin on medication, would have to raise their consultation fees to survive.
      Overall cost would go up.
     

       Patients would have to pay pharmacists to dispense. GPs, unable to compensate by charging a margin on medication, would have to raise their consultation fees to survive. Overall cost would go up.

       If patients find prices too high and seeing GPs inconvenient, they would go instead to polyclinics and overload the public health-care system to try to take advantage of cheaper consultations, cheaper drugs - and then complain of too long a wait, not enough doctors, crowded pharmacy counters, and so on. To remedy this, the Government would have to spend more and probably raise the Goods and Services Tax to fund it.

       In the US, physicians and pharmacists claim from insurance firms for their services. In the United Kingdom, doctors work under the National Health Service. In both countries, physicians do not have to worry about making money from drugs.

       No one funds GPs in Singapore, except their patients. No one, of course, owes GPs a living, but taking away their services means losing 80 per cent of the primary health-care market, as polyclinics cater to only 20 per cent.

       So, how will primary health care look in the future? Will doctors still prescribe and dispense? Will the issue continue to put them and pharmacists on different sides? Or will they find effective ways to collaborate for the health of their patients?

       Some doctors and pharmacists believe there should be neighbourhood health-care centres, where a few GPs work in a group, with a pharmacist and pharmacy on the premises. Such a practice could include nurse educators. There would be team work, better co-ordination and more holistic patient care.

       It would not be unlike GP groups in the UK, except that instead of the NHS footing the bill, it would be patients who pay, and most likely pay more, to cover diagnosis, treatment and advice by the doctor, drugs and directions from the pharmacist, and dressings, injections and patient education by the nurse.

       Since these neighbourhood centres likely would replace the solo-doctor clinic downstairs or in the next block, patients may have a slightly longer distance to walk. But it would be a good compromise in terms of cost and safety as well as convenience.

       To avoid spending much, many patients would need to learn self-management, resort to over-the-counter drugs and look after their own health. People in industrialised countries have been doing so for years, aware that many minor ailments do not really need medication, let alone a visit to the doctor.

       These days, if I have to be in New York in spring, it is not the high price of anti-histamines but literally the pollen and spore from flowers, grasses and trees that bring tears to my eyes. I no longer depend on expensive brand-name pills my doctor used to prescribe. I have learnt to tough it out with tablets and sprays that cost a few dollars and do not require a prescription, from the corner drugstore

    Edgar Koh
    The Straits Times
    27 Sep 07

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    Here's a win-win prescription
    Patients with chronic ailments

       THE thorny issue of separating prescription from sale of drugs reared its head again in Parliament last week, and was raised again in a letter to the Forum pages yesterday from Member of Parliament Halimah Yacob. The chairman of the Government Parliamentary Committee on Health said that pharmacists would provide a counter-check to doctors' prescriptions and improve patient safety.

       But doctors had, in the past, spoken out against the practice of separating the two functions, simply because the move could seriously affect their bottom line. Much of the profit a general practitioner (GP) makes comes from the sale of medicine.

       Health Minister Khaw Boon Wan did not agree that all dispensing of medicine should be done by pharmacists, but suggested that private doctors give all patients a prescription and leave it to them to choose between the convenience of getting the medicine at the clinic and buying it elsewhere. Such a move could help keep a lid on health-care costs, particularly for patients with chronic ailments who need drugs for the long haul. It would be to GPs' advantage in the long run too, as they would be able to keep the patients that they would otherwise have lost to polyclinics for cost reasons.

       GPs already have a ready market among patients with acute illnesses such as diarrhoea or the flu: These patients would certainly prefer to see the doctor and get their medicine all at one go - rather than make an extra stop elsewhere - because they are unlikely to need more than a few days' worth of drugs. But for patients with chronic ailments such as hypertension, the cost of medicine is paramount. They need these drugs long-term - most likely daily and for the rest of their lives. They see the doctor so as to monitor their condition, not because they are feeling ill; they see the doctor also to replenish their supply of medicine, not because they are in urgent need of it. So these are the ones who can - and should - shop around.

       Where possible, a doctor prescribing medicine should let patients choose between a more expensive brand-name drug and its generic counterpart. As it stands now, patients take whatever medicine the doctor has in stock. Most clinics would buy one or at most two types of medicine within the same class. With most of those patients with chronic ailments being older and perhaps even retired, this lack of choice could entail their spending more.

       This is likely why increasing numbers of chronically ill patients are turning to polyclinics, where they make up almost half of all patients. Unless means testing is introduced, it does not take a crystal ball to predict that the number of such patients flocking to polyclinics for the cheaper drugs offered there will continue to go up. Already, polyclinics are telling patients that they can expect a wait of up to three hours in the mornings and on Mondays and Saturdays.

       Many patients with chronic ailments have no difficulty paying a private GP's consultation fee, but they are attracted to the polyclinics, which dispense highly subsidised medicines. Figure this: An elderly patient is charged just 70 cents for a week's supply of one medicine - whether the daily dose is one, two or three pills. Patients with chronic ailments tend to have more than one problem. Someone with a heart problem is also likely to need drugs to keep his blood pressure and cholesterol down. This adds up to several pills to pop daily.

       Unless the private sector can find a way to provide these patients with an affordable alternative, it will lose them to the polyclinics - or even to specialist clinics in public hospitals which also offer subsidised drugs. A couple of pharmacy chains that offer competitively priced patented and generic drugs for chronic ailments might be the solution. Only then would it make sense for doctors to charge patients only for consultation, and write them prescriptions to be filled outside their clinics.

       If patients do not make significant savings, the current system where GPs provide both consultation and medicine will not change. Having competing pharmacies will bring prices down for patients. In Australia, for instance, pharmacists recommend the best deal for patients. They stock a full range of drugs and are obliged to inform patients of cheaper alternatives; they also do call up doctors to ask whether an alternative drug would work just as well.

       In Singapore, polyclinic pharmacies could also enter the market to sell close-to-cost-price medicine to patients with prescriptions from GPs. The result: Enormous savings for patients - and benefits for both GPs and polyclinics. Here is why: Patients may prefer to stick to their family doctor if they can buy their medicine at polyclinics. GPs get to keep these patients, even if they no longer sell them the drug. And the queues at the polyclinics might just get much shorter. It's a win-win situation.

    Salma Khalik
    The Straits Times
    27 Sep 07

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    Pharmacists help to ensure safe and right use of drugs

       WE READ with interest the many articles published in the media on the new Pharmacist Bill and the recent article by Mr Edgar Koh, 'Tough pill to swallow' (ST, Sept 27).

       We wish to clarify that pharmacists are graduates who are drug experts and they may work in a variety of sectors within the health-care industry like manufacturing, wholesale, marketing, regulatory, hospital, community and research. Out of the 1,482 registered pharmacists, 48 per cent work in hospital and community pharmacies.

       Pharmacists in these areas are professionally trained to provide the checks and balances in the dispensing process, which includes reviewing for appropriateness of the prescription, educating the patients on their drugs and potential side-effects, allergies, medical condition, and addressing any concerns the patient may have. Pharmacists do not dispense based on textbook knowledge alone, they are able to elicit pertinent information from the patients and doctors where necessary.

       Last year, there were at least 100,000 documented cases where Singapore pharmacists, in the public health-care sector, intervened to make their recommendations for changes in the prescriptions. Examples of such changes include inappropriate drugs, dosages and duration of therapy; drug interactions; duplication of therapy; and drugs omitted inadvertently from prescriptions. Such pharmacist interventions are made in collaboration with doctors and other health-care professionals.

       In a US study published in 2003, the authors discovered that for every US$1 spent on a pharmacist, US$4.68 of health-care savings was achieved. Ultimately health-care providers would want to ensure safe and quality use of drugs in our patients.

       We support Minister Khaw Boon Wan and MP Halimah Yacob's calls for doctors to routinely give patients their prescriptions, without them having to ask so that they can choose where to purchase their drugs.

       In order for patients to decide where to buy their drugs, doctors and pharmacists should itemise their bills so that patients can make informed choices. This will be especially beneficial for people on long-term medication for chronic diseases as proposed by Ms Salma Khalik in her article, 'Here's a win-win prescription' (ST, Sept 27).

       This is the way forward for a better, cheaper and safer health care.

    M K Fatimah (Ms)
    Vice-President
    Pharmaceutical Society of Singapore
    The Straits Times Forum
    29 Sep 07

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    Missing Articles

      You may have noticed that some of the articles referred to above are not published on this page. This is not (for the cynical amongst you) a deliberate attempt at ommission. Rather, I simply did not save the articles at the time, and I can no longer find them on the 'net. If you have the soft copy, please mail it to me below, and I will be very grateful. :-)





    Questions for discussion

    1. Describe the current workflow from consultation to prescribing to getting medicine in Singapore. How about overseas?
    2. Will making it compulsory to buy medicines from pharmacies bring overall prices down?
    3. Discuss the pros and cons to patients of separating consulation and dispensing.
    4. Conduct a survey of your friends and family. How many people favour such a separation?
    5. Do you think that there is an optimal solution, compromise or middle ground that will benefit everyone?
    6. What are some alternatives that people have suggested?
          Email your answers here.

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