Pioneer Generation Package

The Pioneer Generation Package (PGP) was announced to much fanfare last month. There are several notable features to this package.

1.    First of all, it applies to anyone born in Singapore before 1950. Which means Chee Yam Cheng (~MBBS 73, ~65 years old) just makes the cut but Sonny Wang may not (~MBBS 74, ~64). Life is tough.

2.    Secondly, it’s BIG. $8,000,000,000. There are NINE zeroes in there. And guess what, it is funded from 50% of the nett investment income from our reserves of just ONE year. This is very significant. It shows that our reserves are so BIG that just half of the investment income of only ONE year can fund the healthcare needs of 450,000 elderly people for many, many years. Next year and every year, we will have another 7 to 8 billion dollars of investment income that we can use to fund other things, such as my concert ticket to watch the Fleetwood Mac concert and a MRT line that won’t break down every other week.

3.    Thirdly, there is no means test and everyone as defined to be in the age-group of the Pioneer Generation automatically qualifies without filling a form. This is so counter-intuitive to the government and the civil service that this Hobbit suspects some guys in there are getting seizures just from seeing this get implemented. Trust me, there are civil servants who have sworn an oath on the souls of their grandchildren that they will NOT give a cent to anyone unless a form is filled that demand details that even your priest does not want to know during confession.

4.    Fourthly, the 8 billion bucks is supposed to pay for all the people (~450,000) for the rest of their lives until they pass on. I hope the money will last that long.

There are a few things happening on the horizon that suggest that well, $8,000,000,000 may not be enough.

The first thing is life expectancy. People are living longer even as we speak. Life expectancy is a moving target. As we live longer, we need more care.

This is compounded by doctors (yes, we are the main culprits) practising expensive medicine. Some say that the most expensive medical instrument ever invented is the doctor’s pen. Doctors are the main culprits and also the main victims. Doctors are forced to practise expensive medicine from two forces. The first force is the medical litigation climate. There is a climate of fear developed over the last few years. No one wants to be caught out so more and more doctors practise defensive medicine. No one wants to appear before SMC. Even when the complaints committee and disciplinary tribunal proclaim you innocent, the patient can still appeal to the Minister for Health for a second bite of the cherry. The Minister can, presumably on the advice of some enlightened people, ask SMC to reopen the case, with no reason or rationale given. This hobbit knows of several doctors who have been royally punished in this way. The entire process of why a case is reopened in SMC is opaque and traumatic to the doctor concerned, even if the doctor is not found to be guilty in the end. So as the saying goes:- “Only the paranoid survive”. We cannot blame doctors for practicing defensive medicine if regulators commit actions and decisions that promote this behavior, inadvertently or otherwise.And of course, costs go up. And this hobbit thinks that medical litigation will get more and more common if our legal system allows contingency fees (being discussed now, i.e. paying the lawyers only when he wins). This may encourage patients who think they are aggrieved to more easily sue doctors. There is nothing the medical profession can do if this comes about except to spend more on medical indemnity. As the experience of other countries has shown, this will be largely borne by the patients or their payers.

The second force is how we train our doctors. I.e. the American ACGME-I way. We are fragmenting our system more and more. Do you know that under the current Singapore ACGME-I system, general surgery residents do NOT need to know how to perform gastroscopies and colonoscopies?!?!?! Yes, don’t fall off your chair. In future, general surgeons may not know how to do scopes as they are not required to know them before they are signed off as trained and qualified surgeons. Some sponsoring institutions do mandate that general surgery residents learn how to do scopes, but not all do and its up to the institution to decide. This is because in America, general surgeons usually don’t do scopes, the gastroenterologists do. That means another specialist is involved (more cost) when in the past, only one was needed. This is but one such example.

Another training issue is the workloads our younger doctors are getting used to as they are being trained. A recent conversation with a Head of Department in a restructured hospital is telling: “When I was young, I saw 30 to 40 patients in four hours or a half day’s work. Now that I am older, I cannot keep up this pace. Also, I see more complicated cases referred by my colleagues, so I slow down to 20 to 25 patients for a half-day shift. Now my residents see a maximum of 12 patients per half-day, as dictated by the higher authorities based on ACGME-I guidelines. Then these same residents exit as specialists one day and suddenly they find themselves flooded with 30 patients in a half-day and they cannot increase their work output. They won’t know how to cope. And it will get worse when they get older and cannot work at the same pace as they were young. So what happens then? More will quit for the private sector”.

For the geniuses who rammed this residency system through a few years ago, there is metaphorical blood on their hands as our healthcare system gets more expensive and inefficient.

So going from the above, Singapore Medicine is going to get more and more expensive, even in the subsidized wards of our public hospitals.And the waiting times will remain long too. It is not just due to increased complexity of medical conditions in an ageing population or inflation. A big part of this is due to policies and systems that are inappropriate to our needs.

The next thrust about PGP and caring for the elderly is the emphasis on primary and community care.

The idea is eminently sound. Primary and community care are the places where most people should receive care. There is no need to choke up the acute general hospitals. But this Hobbit has observed several troubling trends in the last few years:

a)   There aren’t that many new GP clinics opening and these new “GP” clinics often offer aesthetic medicine as a major part of the services. In other words, the actual increase in capacity in the private GP sector offering “traditional” GP services may have been quite limited over the years, probably not keeping in line with the ageing population or the increase in population in Singapore.

b)   The A&E Departments of all restructured hospitals offer very good remuneration working as locum A&E MOs, with hourly rates of between $100 to 120/hour. Being an A&E MO is actually a safer bet than being a locum GP, because in the A&E there is always someone senior that you can get advice from on the spot. There is also a triage system that will assign the most difficult cases to the A&E specialists and residents. As a locum GP, you work alone and really, you try not to bug the GP who is on leave unless absolutely necessary.

c)   Career paths have also sprung up in restructured and community hospitals in the form of Family Medicine inpatient departments. This is not necessarily a bad thing, but it does take away a few GPs from the community.

So really, this Hobbit is really worried about who is going to do the heavy lifting in the GP and community care sector. Who is going to start GP clinics, run the FMCs and the polyclinics? That brings us to the rather touchy subject of foreign doctors.

We have relied and will continue to rely on foreign manpower to man our public healthcare services, doctors included. There is no escaping this fact. But there will come a time when a limit is reached. There will be serious issues when more than half of the profession consists of foreigners who are not locally trained. So one can safely say from a manpower planning perspective that for a sustainable environment, locally trained or Singaporean doctors must still make up the majority. Let’s put this at a reasonable figure of two-thirds. Guess what – if you look at the SMC Annual Report, we are there already for the public sector. In the latest available SMC Annual Report 2012, the public sector employed 6716 doctors. Of these, 2222 doctors were neither Singapore citizens (i.e. PRs or foreigners) nor locally trained. That comes up to 33.08%. The corresponding figure is far lower in the private sector. As the saying goes, Houston, we have a problem.

Given a choice, this Hobbit thinks our Pioneer Generation will prefer either Singaporean or foreign doctors who are locally trained. But as the numbers show, they have a one-third chance of not meeting one in the public sector. This figure is probably higher in certain departments and in the long-term care sector. Anecdotal evidence suggests that the public system has problems retaining even foreign doctors. Quite a few of them, especially specialists, actually leave for the private sector once they gain full registration with SMC. So will we have enough doctors, and by even a longer shot, enough local doctors to treat our Pioneer Generation?

All in all, the PGP is a great idea. But the PGP cannot be implemented outside the context of the other components of the healthcare milieu. And until we fix the other issues of our healthcare system, such as a climate that favours defensive medicine, staff retention, doctors’ training, etc, the PGP will face serious obstacles when it is implemented. $8,000,000,000 is a good start. But it won’t finish the job and it may not be enough.

For a start, we need to re-look at the whole system and ask –what are the policies and programmes trying to achieve in terms of the Golden Triangle of Affordability, Accessibility and Quality? It is said that no health system can achieve all three at the same time, maybe two at the best. One out of the three has to be sacrificed.

For the residency system – it is clear that quality is the main target. One may question if quality of training is actually raised by this system or if the system actually produces better specialists, but the intent is clear. By limiting residents’ workloads, mandating that core faculty trainers take off 40% of their time to supervise residents – they are trying to achieve quality. But this must be at the expense of affordability and accessibility since efficiency and hence productivity are severely curbed.

The Pioneer Generation Package is trying to achieve affordability, by declaring right upfront that our elderly do not have to worry about healthcare bills; hence the infusion of $8B over time. And since it is not means-tested, accessibility also improves. Hence by inference, quality is not a priority.

The various primary care and long-term community care programmes we have or that are being implemented is aimed primarily at improving accessibility. Affordability is a secondary objective since primary care is already quite affordable with the polyclinic system and the use of Medisave and CHAS etc. Quality takes a back seat especially in the long-term care sector.

The influx of foreign doctors in the public sector is obviously an attempt to improve accessibility.

Looking at the above, this Hobbit thinks the entire health system is being pulled in different directions by myriad policies and programmes; like torturing or killing a prisoner by quartering (Pulled apart by horses tied to the four limbs of the prisoner). That is why there is so much angst and frustration among public sector healthcare workers, doctors included,today. We need some clarity. Whatever the case, the status quo of this strategic ambiguity or strategic schizophrenia cannot go on. 20 years ago, the government was very clear – it was about achieving affordability – hence the title of the White Paper then “Affordable Healthcare”. What is it now? Is it still “Affordable Health Care”, or it now “Quality Health Care” or “Accessible Health Care”?

At the very least, we can choose two out of the three – such as “Affordable and Accessible Health Care” or “Accessible and Quality Health Care”. Please don’t kid ourselves that we can achieve all three –Affordability, Accessibility and Quality all at the same time. We need to prioritise and reflect this intent clearly across the board in a concerted way and not have programmes and policies that send out wrong signals and conflict with what is the overarching objective of our public healthcare system.