Community pharmacy in Singapore — providing real opportunities
for pharmaceutical care?
Singapore is a city, an island and a country, which
in an area of just over 600 square kilometres manages to be the continent
of Asia in microcosm — at least in terms of its diversity of population.
Of its 3.2 million residents, 77 per cent are Chinese, 14 per cent Malay,
8 per cent Indian with the rest from a variety of ethnic backgrounds.
Almost 40 years after independence from Britain, Singapore still has a
government based largely on the Westminster system, but society is strictly
managed, with rules and regulations sufficient to make many visitors feel
uncomfortable. Importation and sale of chewing gum, for example, is banned
simply because people were leaving gum deposits on the doors of the trains,
leading to disruption of rail services. Of course, a well-regulated society
is not without advantages, and the city is pretty well spotless, and according
to one taxi driver I spoke to, still becoming greener and cleaner.
High standard of health
Singaporeans enjoy a high standard of health with
a life expectancy of 78 years which is little different from ours. At
3 per cent of gross domestic product (GDP) the national expenditure on
health must be low enough to make many Western governments — including
our own, which spends around 8 per cent — envious. However, Singapore’s
health care financing philosophy emphasises personal responsibility, with
individuals being expected to pay part of the cost of the medical service
they use, and all employees have to put 6 to 8 per cent of their salaries
into a special account to help save for medical bills.
Government subsidies help to keep health care affordable,
but like everywhere else, health care costs are escalating.
Pharmacy too is based loosely on the British system,
but with one big difference — prescribing and dispensing have never been
separated, at least in the community. Although this might seem like a
golden opportunity for pharmacists, and one which, at least on the face
of it, many would seek in the UK, it is not what it appears at first glance.
In the community, well over half of the dispensing is done by doctors
and, according to figures from IMS Health, only about 15 per cent of community
generated prescriptions go through pharmacies. In the hospitals it is
a different story with pharmacies distributing medicines in much the same
way as British ones do to both inpatients and outpatients, and pharmacists
providing clinical services on the wards.
The reason for this situation in the community is
historical in that doctors have traditionally had significant representation
within the Ministry of Health and pharmacists relatively little. When
the case is put in favour of pharmacists doing more dispensing, the strong
medical lobby argues that there are not enough pharmacists to do it. With
roughly one community pharmacy for every 20,000 people (compared with
one per 4,500 in Britain), they seem to believe they have a case, but
of course if circumstances changed, a number of pharmacies would open
up overnight.
Pharmacists are allowed to dispense — of course
they are — but the fact is they do not do large numbers of prescriptions
because patients tend to get their medicines from the doctor.
Community pharmacies, therefore, rely more than
pharmacies do in Britian on sales of over-the-counter medicines, some
of which, like British P medicines, can only be sold under the supervision
of a pharmacist. In theory, and to some extent in practice, this gives
pharmacists opportunities in patient care, most obviously in the area
of minor ailments, because they are not spending their time counting and
pouring. Indeed, it is a bit like working in a UK pharmacy without a dispensing
contract, and in my experience that can be professionally satisfying,
if less profitable for the owner.
Opportunity
However, with a prescription comes a patient, and
access to patients is limited for pharmacists in Singapore because doctors
dispense. Or is it? Perhaps pharmacists in Singapore have a real opportunity
to practise pharmaceutical care, and make the most of their four-year
undergraduate degree from the National University of Singapore.
Relationships between pharmacists and doctors, according
to the Singapore Pharmaceutical Association, are not as antagonistic as
might be supposed — indeed younger doctors, in particular, apparently
have a positive view of pharmacists — and like everywhere else there are
pressures to contain the drugs bill and reduce the incidence of adverse
drug reactions. So, if — and as always it is a big if — community pharmacists
can gain recognition and payment for providing pharmaceutical care, their
freedom from having to count and pour should not be one they seek to give
up too lightly.
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