Professor T Walley’s editorial in the current issue of the BMJ is timely (BMJ 1998; 317:487-488, 22 August). He noted that a recent review in Australia found that while across-the-board patient co-payments do reduce medicine use, they reduce the use of both desirable and less desirable medicine. In France, a better system is in place. There, patient co-payments range from 0% for essential medicines to 100% for so-called "comfort medicines". In his editorial, Professor Walley proposed a scheme of A, B, C, D list medicines. The A list is a selection of cost effective medicines, no more than 200 _ 300, but sufficiently comprehensive to allow treatment of all major conditions; in the UK setting these have zero co-payment. The B list medicines are either no more effective than A list medicines, or offer minor benefits at a disproportionate cost; these might require a low payment, perhaps relate to the cost of prescription, to a preset maximum. The C list medicines are those for which effective alternatives are already listed for example, branded preparations where a generic equivalent is available or which are largely directed at patient convenience, such as many modified release preparations; patients might pay perhaps 50% of the cost of these medicines. D list medicines would not be funded by the NHS at all, that is the co-payment is 100%.

The concept of such a scheme is attractive. The pharmaceutical industry is used to operating in countries with co-payment systems. Indeed, the proposal would reward companies for developing innovative medicines of true value and discourage the development of minor variations on existing medicines.

Professor Walley also noted that, "The lists would not be static. Most new medicines would be listed as B or C initially, but a few might reach list A immediately. Medicines could move up or down the lists, as either new evidence or less expensive alternatives became available. The lists could be included in the British National Formulary and in general practice and pharmacy computer systems and updated every six months."

In Singapore, the co-payment system for medicine ranged from nothing in many third-payment systems, to fixed quantums such as in Government Polyclinics to a percentage of the bill. The percentages of co-payment may be based on contractual agreements between patients and the third-party payors as well as the medical diagnoses.

The introduction of additional payments for expensive drugs like Zocor in the Government Polyclinics in Singapore establishes the concept of differential co-payment based on drugs per se, not on the ‘class’ of the patients and not on the medical diagnoses. The White Paper on Affordable Healthcare had defined basic healthcare by exclusion of certain expensive treatment modalities. It may now be important to look into the treatment of common basic conditions as new expensive drugs are now being introduced. For example, the new group of anti-leukotrienes for treating bronchial asthma cost more than $3 each. Drugs like Propecia for treating hair loss and Viagra for impotence are now posing new problems for third party payors.

There is a new challenge to contain the cost of medicine with the advent of new expensive drugs to treat common diseases and to enhance quality-of-life. One response would be a classification of medicine such as that proposed by Professor Walley. K

Your ordinary sick leave entitlement for each calendar year is:
Without hospitalisation - 30 days; With hospitalisation - 60 days

If you exceed your entitlement, your sick leave may be extended on full pay depending on your length of service. The extension varies between 10 days for an officer with more than 1 year’s service and a maximum of 150 days for an officer with more than 31 years’ service. Thereafter, if you have also exhausted your annual leave, you can only be granted further sick leave on full pay on the recommendation of a Medical Board. Such leave will be limited to one month for every 2 years of completed service.

Unrecorded leave

Additional paid leave is given each year to:

• serve in Singapore Volunteers Overseas Programme

Dear fellow colleagues

It has been 4 years since the birth of the SMA MO Committee. The Committee was formed then by 6 young and idealistic volunteer doctors, all sharing the same vision and hope that they could somehow make things better. They saw the need for junior doctors to have a united and strong voice that would be heard instead of disparate rumblings in staff lounges and canteens. Hence, the SMA MO Committee was formed.

I am glad to say today, that they have done much and had participated actively and positively in improving the life of junior doctors. The SMA MO Committee to-date is the only entity which represents junior doctors and I dare say has a definite role to play on the medical scene.

Although most of the pioneers have left the Committee, their work has through the years managed to attract other like-minded and committed volunteers. As the newly appointed Committee this year, we hope to continue the untiring efforts of our predecessors to serve and represent all junior doctors. We will continue with stalwart programs like the well-received annual HO Seminar, MOPEX Bulletin Board and the MO Column in SMA News. On top of that, we have on our work plan many new and exciting initiatives, for instance, we will be introducing many more articles written by our peers into the SMA News. Furthermore, we also have a few projects lined up to look into various aspects of junior doctors’ lives. These are but a few. Please watch out for them.

DR FOO CHUAN KIT
CHAIRMAN, SMA MO COMMITTEE