Warning – this is NOT going to be a funny article. It’s a long and serious one.
For as long as most of us have been alive, Singapore has been a regional medical hub. But then again, it was not always so. Rangoon (now called Yangon) used to be a medical hub. Then Hong Kong. Singapore was not a medical hub. In fact, the first products of our local medical school were not even given a Bachelor’s degree. They were given the qualification LMS (Licentiate in Medicine and Surgery), with the proviso that having the LMS did not allow them to take postgraduate UK exams such as MRCP, FRCS etc. The first person with a LMS to do so was actually a Ceylon-born doctor, Dr Michael Emmanuel Thiruchelvam from Ipoh who had to sneak in to take his FRCS and passed it in 1929.
Indeed, Singapore has a few inherent strengths as a medical hub. These include its geographical location and connectivity as a travel hub. The good infrastructure it enjoys is also a plus, such as the safe blood supply that Mr Lee Kuan Yew talked about recently at the SMA Annual Dinner. But many of these pluses can be eroded by technology and competition. For example, a major centre in Kaohsiung Taiwan can routinely do a liver transplant withoutany blood transfusion.
So it cannot be a given that Singapore will remain a medical hub. So on this National Day, let this Hobbit share with you what keeps him up at night, and ask ourselves – are we sure we will still be a medical hub in say, twenty year’s time?
Public-Private Sector Divide
No regional medical hub ever developed unless the private and public sector worked together. Our two sectors remain deeply divided and talent is deployed sub-optimally. After years of talking, there hasn’t been much progress. The private sector chaps feel they are shut out by the public sector folks out of envy or protectionism and are paid a pittance. The public sector chaps feel that even when the private sector folks who come back intermittently lack commitment and accountability. The solution is perhaps to let the private sector people come back and work with clear accountability and adequate remuneration.
We need more resources, porosity and accountability in this matter. Maybe we should start with a pilot with a selected team of private sector specialists in one progressive public hospital.
Policy Consistency with the Private Sector
The government is sometimes perceived to be a bit schizophrenic with respect to the private sector. Some agencies are perceived to be facilitators and encourage the development of the private sector, such as EDB and IE Singapore. Others vacillate between engagement and containment.
Take the example of private hospital land and development. No one really knows what the government really wants in the long term. Sometimes, it is seen to encourage this, with the release of two private hospital sites in quick succession. But nobody really knows when the next site will be released. Will it be next year or 10 years from now? How many more private sector beds does the government want in the next 10 years? And this opacity applies to nursing home planning and GP clinics as well.
Playing cards too close to the chest creates uncertainty and businesses and people don’t like uncertainty and inconsistency. That also leads to gyrations in costs and prices which the healthcare sector can well do without.
Healthcare is not a Property Play
Speaking of private hospital land, that leads us to the next point. You cannot develop a healthcare hub when the property imperative dominates the agenda, even when the issue of property prices directly affects only the private sector. You know something is seriously amiss when clinic rental bids for a 600 square feet HDB shophouse in Punggol exceed $32,000 a month and the price of the last piece of private hospital land is the same as that of Marina Bay Sands – 1.28B (excluding GST).
The market fundamentalists will always say the market will sort itself out. Well, maybe the property market will, but in the meantime, the private healthcare market pays the price in terms of competitiveness and affordability.
The notion that even when rentals and prices drop, doctors will not drop their prices is not a truism. Doctors’ charges vary a lot. Those that charge a lot do not always pay high rent. But those who pay high rent are forced to charge a lot.
Healthcare involves risk because healthcare involves uncertainty. Uncertainty arises from our imperfect and limited knowledge of the human body and from the genetic variation within the human race. And this uncertainty is amplified when out of necessity, less experienced doctors in training are working and when there are large patient loads.
Therefore, while we want to safeguard patient safety, regulators cannot take a risk-free approach to healthcare regulation. Regulators too need to take risk so that the practice of medicine can reasonably take place. But increasingly, we see regulators take a risk-free approach to healthcare regulation. When something goes wrong, responsibility escalates upwards – the consultant is responsible. Or when something goes wrong, we tighten regulations to the point when the environment is stifling, if not suffocating.
Take the example of the medical device regulation. There was nothing much urgently wrong with the existing system, and regulating medical devices is at best a pre-emptive move to prevent problems in the long run. It is good to pre-empt problems. But when the regulators wanted everything regulated tightly and quickly, the practice of medicine became either stifled or frightfully expensive. A light and slow touch would have been better. If only the regulators took some risk and not passed on all risk and cost to the product importers, wholesalers and distributors.
Another example is the IVF sector. After an IVF baby mix-up in the private sector, all IVF centres have had to adopt the Australian RTAC standards. We practiced risk-free regulation by relying almost 100% on foreign standards (like residency). This effectively stifled the IVF donor segment because RTAC guidelines required that all IVF babies have the right to know the identity of the donor when the baby reached adulthood. Think about it, how many sperm or egg donors want a person coming 20 years later to claim he/she is your offspring? Singapore probably just lost another few babies.
There is also a difference between regulation and accreditation. Regulation sets the basic standards while accreditation involves best practices. That is why regulatory requirements are mandatory while accreditation standards are optional. Yet, because we have risk-free approach to regulation, foreign accreditation standards have become mandatory in the local context. Again, costs go up. At the same time, decades of local experience in IVF regulation is slowly degraded as RTAC requirements come into force.
A healthcare hub cannot develop when there is a risk-free approach to healthcare regulation. Policy and regulators cannot always be allowed to fall back on the mantra “I cannot take the risk, therefore….” Medically-trained regulators are not different from other doctors – they are paid to exercise judgment, and judgment includes taking and managing risk.
Costs, Costs and Costs
At 47, Singapore has lots of money. So much that sometimes, we don’t think twice about spending it.
We are on a building spree now in the public sector. Hospitals are being built at a faster rate than even the nineties when three large hospitals were built. Nothing wrong with that. We need these hospitals. And then there is the challenge to build each hospital better than the last. Well, someone should take a look at the cost. The costing used to be about $1M a bed for a general hospital. Now it is rumoured that it’s going to cost >1.5M a bed (excluding land cost) because every hospital planning committee wants to build a better hospital than the last. And at >1.5M a bed, we are building new hospitals that still have 65% of beds that are un-airconditioned. We must be the only First World country in 2012 that are still building un-airconditioned wards in general hospitals and yet we are spending so much on a per bed basis.
Another example is the GP IT system being developed. My colleagues who are using the prototype say it’s a system with many features. Only problem is no one really knows who is going to pay for the upkeep of the system when the trial run ends and the system is deployed on a large scale. From the look of things, if there are no subsidies, the average GP will have problems maintaining such an expensive software. Can we live with a simpler and cheaper system? I have a simple suggestion. Let the bureaucrats and software designers write a two page justification for each and every data field and software feature they want to incorporate and I think we will have a simpler and cheaper system straightaway. This can be applied to the software for the reporting of data for CHAS, CDMP etc as well. How many features on the smartphone do we often use anyway?
And this Hobbit is not even going to begin to talk about the 100M proton therapy thingy….
The best things are simple and easy to use. If we are serious about being a healthcare hub, we need to simplify stuff and spend money wisely. We need reality checks along the way.
And finally, People……
I left the most important for the last – because healthcare is ultimately about people. We need to raise a generation of healthcare professionals who are focused on getting the job done and who have the right ideals. But if you go to the ground and talk to the young doctors now, you will quickly realize this is possibly the most confused and embittered generation of doctors we have had for a long time, if not ever. This applies to those MOs who graduated around 2004 and now. They come in various descriptions. I will just list a few here
- People who were given BSTs when BST positions were liberalized a few years ago, only to find out that AST positions were still the same small number and they couldn’t get a registrar post anywhere. There are quite a few of them with MRCS now working as GPs
- BSTs and ASTs who have to work harder than residents and some ASTs who even have to supervise residents and wondering why must they suffer while others have all the good stuff.
- BST Trainees who have had to lose seniority and start all over again as residents when the residency system was introduced.
- Doctors who cannot get a residency and are bounced around like ping-pong balls.
- Folks who are affected by the abrupt cancellation of the AST positions.
- Male doctors who are finishing NS and realise now they have to compete for residency places with more junior doctors and they suspect that many residency places have been reserved for final year medical students and housemen and they, the more senior chaps may have lower priority.
- Residents who have to fight tooth and nail for cases with their colleagues and often wondering at the back of their minds – am I an inferior product? Why do I have to be the guinea pig?
- Medical students who now instead of thinking about getting a proper education, think of landing the choice residency as soon as possible. There goes the innocence and the idealism. Remember, these medical students are very bright, and have no problems understanding that unless you get a residency as soon as possible, you are in a rut. And they will do what it takes to avoid that.
- Residents who now instead of focusing on learning the right skills and experience, have to think of passing exam after exam because while we are ready to embrace residency, we do not have the courage to ditch the British or Singapore exams. At last count, an GS resident had to pass at least 6 to 7 exams (In-Training Exams, MRCS, FRCS, exit exam, +/-USMLE). The same applies to residents in other programs too. Residents are being examined to death. Will more exams make a better specialist?
It is easy to say that these people are affected because of difficulties in the “transitional period” of introducing a new system of training, as if though the word “transition” can cover a multitude of sins and sooth the deepest hurts of what can be opined as a botched implementation of a bad idea. Each and every young doctor who has been adversely affected by this “transition” has only ONE professional life to lead. He cannot turn the clock back and have another go in his career. It’s no use telling them “sorry for screwing you, it’s because we are in transition”.
Has anyone important really sat down at the table and talked to these poor young doctors and final year medical students? Many of them are angry, disillusioned and confused. And these wounds that have needlessly been inflicted on them may heal eventually, but the scars remain.
Can such a scarred bunch of people make up a medical hub in twenty years time? At 47, we should be mature enough to be brutally honest with ourselves, ask the tough questions and face the hard truths. If not, it is quite unlikely that Singapore will remain a medical hub when it is 67.
9 Aug 2012