What NOT to Spend 7.1 Billions Dollars On…..

This latest budget for Ministry of Health has been announced and it is a whopping $7.1B. That is $7,100,000,000. And it is 22% more than last year. This is just great. MOH budget is growing faster than this Hobbit’s waistline, the COE and the price of beer at Kopitiam combined. It shows that the government is really serious about devoting more resources to healthcare.

At the same time, we should also ensure all this money is well-spent. So this Hobbit will now give some unsolicited and as usual useless advice to the bigwigs and bean counters in the Ministry of Finance on how to monitor and ensure how the $7.1B is spent. Given the limited intellect of this Hobbit (who had no A* in PSLE, did not score straight As at A levels, was never on the Dean’s list and most humbling of all, did not qualify to receive tuition from the most august Singaporean education institution of all: Learning Lab), this Hobbit actually doesn’t know what the money should be spent on. But this Hobbit does know what the money should NOT be spent on.

 

1          Another Cluster/Declustering/Reclustering Exercise

Speaking of clusters – please do not muck around with clustering, de-clustering and re-clustering exercises. It started in 2000 with the formation of Singhealth and NHG. Since then we had reclustering with NNI joining Singhealth and declustering of NUH and KTPH (Alexandra Health) from NHG and CGH from Singhealth. Many millions have been spent on these clustering exercises that to borrow a crude American term – it’s one big clusterfXXX.

According to the authoritative Wiktionary:

clusterfXXX (plural: clusterfXXXs)

1.    (slang, chiefly military, vulgar) A chaotic situation where everything seems to go wrong. It is often caused by incompetence, communication failure, or a complex environment.

Blame the dwarves for teaching this Hobbit such a vulgar word. But it’s really apt here.

2          Another Branding Exercise

Even if we do not spend money on clustering exercises, we must also avoid spending money on branding exercises. Branding exercises inevitably involve change of logos, letterheads, signages and uniforms and all these costs buckets of dough. It also creates a lot of confusion because just when you thought you figured out who is the staff nurse, nursing manager and health attendant, they change the uniforms again!

Having said that, this Hobbit is inclined to make one exception – Alexandra Health. Why is it called Alexandra when it is no longer in Alexandra but in Yishun and it is also set to sink its teeth and take a big bite out of Woodlands? To top it off, Alexandra Hospital is now managed by Jurong Health. This is even more confusing than figuring out the MCE.

3          Do not spend on yet ANOTHER trip to the Geisinger Health System if we are NOT prepared to accept the truth

We have sent many, many delegations to this fabled hospital/health system operator in the United States. This Hobbit has nothing against Geisinger. It’s probably a great place for doctors because it is physician-led (or that’s what the website says). But the most important lesson from Geisinger is one that we are unprepared to learn – which is it is a “closed-enrollment” system. You only get into a Geisinger facility if you  are already a member. That is why they can introduce all the right-siting and quality improvement programmes. The same applies to another system that was the flavor of the month about five to ten years ago – Kaiser Permanente. But obviously there is no such thing in Singapore – you can walk into a NHG Polyclinic in the morning, go to CGH SOC in afternoon and get seen at NUH A&E in the night. All in the name of patient choice.

Well, you can’t have it both ways, chum. So stop wasting money making long trips across half the world learning about closed enrollment systems when we do not have the political or administrative will to make our clusters closed enrollment systems. There are other easier ways to log frequent flyer miles.

4          A Proton Therapy Accelerator that costs US$100 million dollars

It was announced some time back that the public sector will have its proton therapy accelerator. It is rumoured that such a piece of machine will occupy a lot of space and cost something to the tune of US100M. Maybe things will get cheaper with time. But a course of treatment now in the USA on this machine is supposed to cost tens of thousands of dollars. Will we be much cheaper? Who is going to pay for it? Medishield Life? What is more,current evidence shows proton therapy outcomes are superior to other therapies only for paediatric, base of skull and maybe prostate tumours. Of course it is the prerogative of a private hospital if it wants to spend money on this. But to spend public money on such expensive and limited-use machinery is another thing altogether.  Maybe it’s just for Bragging rights (pun intended, for those of you who know what proton therapy is all about.)

5          A GP IT System that costs a bomb to develop and an arm and a leg to maintain

The much vaunted GP system that received funding from MOHH and developed by a local IT company a few years ago that was rolled out to certain GPs on a trial basis is going to bite the dust soon. Apparently, no one really wants to pay for the full upkeep of this system and the IT vendor has decided to pull the plug. Affected GPs have been informed already and the transition is going to be a painfully expensive one.

Actually, there are already two or three off-the-shelf GP IT systems that dominate the local market. There is no need to develop another one that costs a lot of money. Someone just has to eat humble pie and go to these dominant vendors and ask them to develop a common interface or platform so that the private GP clinics can operate or be linked together on a common platform. That’s it. Simple. No need for complex proprietary systems that have all the bells and whistles that no GP is going to pay for. They don’t need all this stuff. So, even as we bury this current GP system, please do not spend more money on another complex one. The old acronym KISS still applies – Keep it simple, stupid.

6          Pay American organisations (or any foreign body) to teach us how to train doctors and conduct exams which are not even recognised in the United States

Many years ago, our colonial masters allowed a medical school to be built in Singapore. But in order to maintain colonial supremacy over local medical graduates, the school was allowed to only confer LMS diplomas (Licentiate in Medicine and Surgery). The LMS graduates were not eligible to sit for membership exams in the UK (i.e. MRCOG, MRCP, FRCS etc) that were recognised as specialist qualifications. In other words, LMS was a dead end with no potential for one to be a specialist. And so many local graduates were repressed. They were often assigned to be Assistant Medical Officers to work for European doctors who in no way were clinically superior to them. One Malayan-born Tamil doctor Dr Chelvam with LMS actually managed to fool the examiners and sneaked in and passed the FRCS in 1929 and broke this glass ceiling.

Obviously no one learned from our bitter history and now we have surrendered our rights to conduct training and examinations to the ACGME-I system. So nowadays, even if our residents passed the exams in ACGME-I, (the suffix “I” meaning international), they are also not recognised for practice in USA where the ACGME system originated from.

So we have gone more than full-circle – we have actually deteriorated from our colonial days to something even worse – our LMS graduates in the past cannot take membership exams but now, our residents, after passing the ACGME-I (which is at least 80% similar to ACGME) exams, are not recognised for practice in USA.

So please, do not spend money on training systems and exams that are not even recognised by the countries from which they originated.  We are no longer under the colonial yoke.

7          Building under-sized hospitals

Many new hospitals are being built. After Sengkang, we may only need another two general hospitals. But maybe more are being built. Which is kind of scary. It takes a lot of time, money and people to start a general hospital.

It is probably better to have bigger but fewer general hospitals for quite a few reasons. Firstly, there is more flexibility. In the event that there is over-capacity in the system (if that ever happens), it is easier to close wards and clinics than to close entire hospitals. Secondly, you save on manpower costs because you don’t need separate departments of IT,finance, HR etc. Thirdly, you don’t need another set of CEO, CMB, CFO and another set of mission, vision and core values which seriously, no one remembers.  And most importantly, you also save on land because one big hospital takes up less land than 2 hospitals. The extra land can be used for park connectors and cycling tracks so that foreign-looking cyclists who don’t pay COE don’t have to rant at our motorists on our already congested roads.

Therefore, would it not have been better if KTPH had 1200 beds instead of having both KTPH (only 550 beds) and another hospital in Woodlands? We should learn from the mistake of building an under-sized general hospital as in the case of KTPH.

8          Do not spend on building someone’s legacy

Finally, humans are fallible, proud and mortal beings. Most of us want to be remembered well after we are gone. We want to leave behind legacies. Legacies can be free or frightfully expensive. People who control financial resources should guard against approving expenditure that may look reasonable and necessary but if you look closer, it is nothing more than something that materialised from the mind of a senior chap who wants to leave behind a legacy after his retirement. You may never prove with hard evidence that someone wants to leave a legacy behind. But like a pungent fart, you can smell it…..just look around us…..