Another White Paper

There are white papers and then there are white papers. The recent Population White Paper will forever be unfortunately associated with the infamous figure of 6.9M. But not all white papers are as controversial as this one. Twenty years ago, the Government also published another White Paper. It was titled “Affordable Health Care” which served as a blueprint of sorts for Singapore for about ten years until a generation of folks running healthcare sort of ignored or forgot about this landmark WhitePaper and its recommendations.

This Hobbit thinks the Affordable Health Care White Paper was quite coherent and focused in its approach. Far more than what is happening in recent years, unfortunately.

So for those people out there who think that because a population upper limit of 6.9M was mentioned in the population White Paper, it will surely come to pass, fear not. The following will show that even if they are mentioned in a white paper, people can still forget about it or even do the exact opposite. This Hobbit gives a few such examples that were found in the Affordable Health Care White Paper which have not come to pass even now, twenty years later.

Philosophy

“Any health care policy has to trade off among four competing goals:

 

  • Equitable access;
  • Freedom of choice forpatients
  • Affordability; and
  • Freedom to organise production and to price

 

…”Given Singapore’s environment, we have to compromise the last goal: freedom to organise production and to price. (Page 13)

Except for the egregious example of the Susan Lim case, the private sector now has total freedom to price. In fact, freedom to price has been enshrined by the Competition Commission of Singapore when it outlawed the SMA’s Guidelines of Fees.

Basic Medical Services

“The Government has promised Singaporeans access to affordable basic medical services. This basic package will reflect good up-to-date medical practice, but it will not provide the latest and best of everything” (Page 17 to 18). “MOH will define the basic medical package which all Singaporeans will have access to, as it has always done”.(Page 21)

Actually, no one really knows what is the basic medical package (BMP), a construct as nebulous as the this year’s epic haze. We only know a few examples of what is NOT in the BMP.

The closest we have to a BMP is really what is claimable under Medisave and Medishield. But then again, there is a lot of funny stuff happening in Medisave too. For example, up till now, ultrasound-guided excision biopsy of breast lump, which is curative, is not claimable under Medisave, even though the scientific literature provides solid evidence supporting this therapeutic modality. People have been told to claim under (non-therapeutic) diagnostic breast lump biopsy. Either the folks in Medisave are living in the Stone Age or they do not know they are actually asking breast surgeons to deliberately code wrongly for what they are doing.

Private Sector Share of Hospital Sector

“The private sector presently provides 20% of acute hospital beds, mainly at the higher end of the hospital market. There is room to increase their share to 30% by 2010”. (Page 31) (According to Table on Page 37, this figure excludes A class beds in subvented hospitals and there will be a total of 9,690 beds in acute hospitals in 2010)

According to the Health Facts Singapore 2012 published by MOH, in 2010, there were a total of only 8064 acute hospitals beds, of which 6686 were to be found in the public sector and only 1,378 beds (17.1%) were to be found in the private sector.

There are another 2,195 beds in the public sector that were classified under “specialty centres” and not under “acute hospitals”.  Presumably this large number of “specialty centres” beds can be accounted for by IMH?

In other words, we are a long way off from the 9,690 acute hospitals beds that was forecasted in the 1993 White Paper, even if we take into account the opening of Jurong General Hospital in 2014.

Bed Class Distribution in Subvented Hospitals

“Fewer patients are choosing Class C, and more are opting for Class B2 or better. This trend will continue”; “Presently they (Class C beds) form 33% of beds in subvented hospitals. MOH expects this proportion to fall to 25% by the year 2000” (Page 36 and 37)

Again, this is way-off as experience tells us that there is great demand for Class C beds. SGH originally did not offer any C beds when the hospital was rebuilt in the seventies and eighties. That was described to be “a mistake” in 1989 and C class beds were built in a very limited way. Then in 2001, SGH had to offer C class beds in all disciplines.

We also know in other hospitals, waiting times for C Class beds are always the longest and the most frequently “up-lodged”. If you consider all the up-lodging that is happening everyday, then the actual demand and utilization of C Class beds could well still be around 33% today.

Private Wing?

“A subvented hospital may want to develop additional Class A wards or clinic suites, in order to offer new unsubsidized services. It may do this on its own, like any private hospital, provided the project is commercially viable and can be funded on a commercial basis without Government support. The project should preferably be run as a separate company with a different corporate name and image. Physically the additional facilities should be as distinct as possible from a subvented operation, e.g. in a separate bloc, which for practical reasons can adjoin the public hospital” (Pages 37 to 38)

This is an interesting one. If you read the words carefully,the term “private wing” is never mentioned. But the passage certainly describes a private wing in every sense of the word. However, no subvented hospital has a private wing today. Is it because there is no demand and there were no requests for a private wing to be built? Or is it because MOH has never approved the building of private wing? We may never find out….

Medical Research

“Improvements to the healthcare system do not depend on indigenous breakthroughs in medical research. While medical research increases the pool of human knowledge and can improve the quality of health care, it generally does not yield any financial returns, even over the long term”. (page 51)

This is a strong statement that bears reading over and over again. Yet, we are now building not one but two academic medical centre campuses (SGH/Outram and NUH/Kent Ridge) that will soak up billions of dollars of resources.

Medical Research

“The third category of research should be undertaken only with strong justifications. Even then we must be careful to avoid raising unrealistic public expectations that the new procedures and drugs will become universally available, and will successfully treat conditions which were previously untreatable”

 

Third Category:

“Research that has practical applications which are expensive, e.g. organ or bone marrow transplantation. Such work is often developmental, involving experimenting with new procedures or drugs that have been developed elsewhere. It can thus raise health care costs without commensurate returns. (Page 52)

Again, this has been turned on its head. One just needs to read the papers and find reports of groundbreaking research on rare diseases,expensive drugs, robotic surgery etc. One may argue whether such research is good or undesirable but this Hobbit thinks no one can deny that the frequent reports of such work have certainly raised unrealistic public expectations about what treatment modalities can become universally desirable.

Postgraduate Medical Training

“MOH is responsible for coordinating postgraduate and advanced medical training at subvented hospitals. Because of the expense involved, and the need to deploy talent optimally, the training of specialists should be based on service needs. It must be centrally coordinated and periodically reviewed”.

This example is one of a flip-flop in thinking. Long ago, everything was centrally controlled. Then, everything was decentralized. First, restructured hospitals can recruits as many trainees as they could, to the point that trainees who have passed their postgraduate degrees like MRCS cannot find advanced specialty trainee or registrar jobs. With the introduction of the ACGME-I system, residency decisions were passed to the residency advisory committees (RACs) sponsoring institutions, program directors etc. Well, these guys took their jobs seriously and decided to promote some residents they thought were good to senior residents. Then in one fell swoop,some wise guy decides to unilaterally overturn this and override the governance structure that had been set in place, even reverse some promotions (promotion letters already sent out) of some residents.

So it has been centrally coordinated, then divested to the sponsoring institutions and RACs, and then now abruptly centralised again.Couldn’t everyone have been spared all this anguish and angst by just sticking to the doctrine of centralisation in the first place?

Should we have another White Paper on healthcare?

Lately, white papers may have gotten a tarnished name. But lest anyone misunderstands, this Hobbit thinks that having a healthcare white paper once in a while is a good thing. The above examples are just a few examples of what did not happen. Some recommendations were quite off the mark, but many did not happen not because these original recommendations were wrong, but probably because conditions have changed or some folks have decided to ignore the prudence that the White Paper was trying to inculcate. And to be clear, many good things did come out of the 1993 White Paper.

A White Paper forces policymakers to think long term and commits them publicly to a course of action that has been carefully thought through previously. Such commitment requires gumption, clarity of thought and allocation of resources. Not everyone may agree with what is written in a White Paper, but it also puts everyone on the same page. There is no ambivalence and vacillation in a well thought-out White Paper. That sure beats making plans in secret with minimal consultation, making things up as you go along or unleashing nasty surprises on stakeholders. The residency is one such bad example. There was no light on how the decision of using the ACGME-I residency framework was arrived at; in retrospect, clearly no in-depth understanding of the resources that were required to operate the ACGME-I framework; and no roadmap for career progression of residents (hence the sudden decree to overturn certain promotions). And hence, it is now still mired in darkness and people down in the trenches have to try to make the system work by instituting ‘patches’ haphazardly like engineers and technicians trying to fix some nightmare software programme. And this Hobbit reckons we will still be mucking around for a long time to come.

We actually need another white paper on healthcare. The last one in 1993 was a good piece of work. We can have another one that is just as good, if not better.

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