Sept 27 - 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.

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.

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