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The recent publicity blitz of the Pharmaceutical Society of Singapore (PSS) asserts that patients with minor ailments can consult retail pharmacists as an alternative to doctors. This is done in the name of cost containment. The Singapore Medical Association wrote to PSS to seek clarification. We publish in this issue the exchange of letters between PSS and SMA. 

It is pertinent to note the comments raised in the Sunday Times editorial (28 Dec 97) “Let’s Cut Out The Doctor?” which reflect what the public feels. The editorial raises the issue of the pharmacist’s competency in separating the patient’s complaints from hidden, more serious illnesses, and asked the SMA to make a public response. We held our comments until PSS affirmed its stand in a letter received on 31 Dec 97 and our response to the editorial was published in the Forum Page of the Straits Times on 2 Jan 98.

This President’s Forum looks at this issue from a different aspect. It is important that we realistically address the issue of the role of the pharmacist on cost containment in the Singapore context. It is inappropriate for the PSS to use the situation in Western countries to suggest that the expanded role of the retail pharmacist is a major solution to cost containment in Singapore. More important, perhaps, is whether the content of the University course in Singapore and the post-qualification experience of the average Singapore retail pharmacist, makes him qualified to assume this proposed role. Moreover, the Singapore healthcare system, having evolved differently, already provides accessible primary medical services to all.

The answer to cost containment is multi-factorial. Worldwide, countries are grappling with the issue, some more successfully than others. The general solution lies in each party in the health care delivery equation, including the patient, doing his part. The issue of cost containment can be reduced to an equation with two fundamental players; the supplier, who should not supply unnecessary health services, and the consumer, who should not over-utilise health services. We also have to presume that the supplier and consumer know what is actually needed for treating the disease in question.

What is over-supply and what is over-utilisation will be clear cut only at the extremes. In real life, there is a margin of over-supply and over-utilistion that society has to accept pragmatically. There will be situations where the patient will want more services, including medications, just to feel safe. There will also be situations where the doctor will conduct one or more tests than usual, to reassure himself that he is not missing out something serious. The heart of cost containment therefore lies in helping the doctors, pharmacists, other healthcare providers, and even the patient himself, determine what is needed and what is not needed. Everyone has a role in healthcare containment. There must however be no subterfuge and no concealment of interest.

The patient needs help and advice on what action is necessary, and what is not, for his ailment, minor or not. This may range from a visit to a doctor, or a decision to self-medicate, or to adopt symptom resolving behaviour (see flow chart on N3). To help the patient make better decisions is therefore an important step in cost containment, and every healthcare provider has a role to play. However, correct decisions presume that both patient and adviser know what is needed, and this is often not the case.

The flow chart shows how the patient typically responds to ‘minor symptoms’. Note that decision nodes are labelled ‘wants’ because patients may not know what are their ‘needs’.  This differentiation is important because  for cost containment to occur, professionals must respond to ‘needs’ rather than ‘wants’.

To suggest that cost containment will result solely because patients seek advice from pharmacists for ‘minor ailments’, simply because pharmacists do not charge consultation fees, is misleading. If this is presently possible, it is because pharmacists are temporarily under-utilised. The ability of pharmacists to provide ‘free advice’ on ‘minor ailments’ may not last long.  After a time, the professional fees of the pharmacist will be factored into the cost of the medicines sold _ especially when the demand for such ‘free advice’ requires the employment of another pharmacist to service these demands.

If it is clear that the PSS’ proposal does not provide true sustainable healthcare cost containment, why is the SMA so troubled by this?  After all, in time, the patient will realise that there is indeed no saving to be had from consulting the pharmacist first.

The SMA is indeed troubled, but by a more important point. It is frequently impossible for the patient to tell if his ‘minor ailment’ is actually minor. Take coughs, for a example. The patient may think all he has is a cough, and this is a minor ailment.  Can he _ or the pharmacist, on the basis of asking questions _ tell if there is accompanying wheezing, or poorer air-entry on the left lower zone, or basal crepitations?  In this example, the patient only knows what he ‘wants’ for the symptoms, and the pharmacist only knows what he ‘wants’ to treat the symptoms, but neither actually knows what the person NEEDS for the disease. Similar parallels can be drawn with every ‘minor ailment’. In such a situation, a delay of appropriate treatment and the potentially serious consequences thereof, makes one wonder if cost containment _ even if can be achieved in the way proposed by the PSS _ will not be replaced by the much higher costs of the tertiary medical care that has unnecessarily resulted. The SMA objects to the PSS’ proposal precisely because it further encourages this potentially serious trend that results in a delayed definitive diagnosis.

The Sunday Times editorial urges that the patient’s welfare be put first. We whole-heartedly support this. We argue that treating symptoms in the absence of a definitive diagnosis is never in the patient’s best interest. We strongly feel that in no cases should the patient’s welfare be sacrificed, especially for cost-savings that may actually be no more than mere delusions.