August Attacks!

The recent National Day Rally by the Prime Minister was in this Hobbit’s opinion, rather light on content in some aspects. Maybe he is saving the heavy artillery for next year when we celebrate our 50th National Day. You know it’s National Day Rally-lite when a delay in the construction of a regional health system general hospital becomes a key item in a National Day Rally. There are many other delays that are more worthy of mention – these include delays to MRT services, delays to HDB flat construction, delays to clearing Causeway checkpoint, delays to the Kong Hee trial and of course the very traumatic delays to anybody’s teenage daughter’s period. Why pick on a hospital? To this and all other delays, we should learn from the Hong Kong T-shirt inscription: Delay No More!

Yes, we are facing a bed crunch in our public hospitals but there are many ways to tackle this. Many of these hospitals have seen their Average Length of Stay (ALOS) statistic go up rapidly in the last few years. The usual reason offered is that patients are now older and hence have more complicated problems that demand a longer stay. But if you think about it, demographic and epidemiological factors do not change so quickly (over just three to five years) as to bring about longer ALOS figures in some restructured hospitals.

Is care now more fragmented and so nobody makes the big decisions? Do senior staff see the patients frequently enough to make important discharge decisions? More importantly, does the system back the doctors to make such discharge decisions, because such decisions are unpopular and involve risk. Are there disincentives so that patients and their families do not want to stay longer than necessary in our restructured hospitals. Are there enough community hospitals and nursing homes beds to help with the discharges’ needs?

If all general hospitals bring down their ALOS by one day, we have “created” the equivalent of about 1500 beds into the public healthcare system. That’s like one more TTSH or SGH. If we cut by half a day, we have another KTPH or CGH.

In fact, with the Pioneer Generation Package and Medishield Life coming on-line soon, the problem with discharging patients and keeping ALOS down will get worse, as the attractiveness of staying in a restructured hospital’s subsidised bed will only increase.

Let me give you an example. Yesterday my part-time clinic cleaner told me of her problems. She earns about $1,000 a month serving three clinics in the vicinity and stays in a 3-room HDB flat with her husband. The flat thankfully is fully paid-up. They have no children. Her 64 year-old husband suffered a stroke recently. He is now bed-bound and needs to stay in a nursing home. The medical social worker (MSW) in the restructured hospital helped her get a placement in a nursing home. She was told she was getting the highest subsidy rate possible for her husband to stay in a nursing home – 75%. That sounds like a decent deal. But the total amount came to about $1450 a month. She still has to pay another $500 to $600 to the nursing home. On top of this, she still has to pay for other expenses such pampers, medicines and transportation costs to hospital for further treatment and follow-up etc. The comes up to another $500. The husband also gets an Eldershield payout of $300 a month for about 5 years.

In other words, even with a 75% subsidy rate and being subsidized at about $1500 a month, she has nothing left to feed herself from her $1,000 a month income.

As suggested, she can rent out one of the bedrooms in her flat and collect say $700 a month but (rightly so,) she has come to the conclusion that keeping her husband in a C-class bed is really the best option for her. The best care, the best facilities at the cheapest price (after Medisave and Medishield Life payouts). And yes, she thinks she may still rent out the HDB flat room and take the $700.

Many people in similar situations will likewise come to the same conclusion and resist moving to a long-term care facility.

Houston, we have a problem.

On a lighter note, the government recently posted another minister of state and permanent secretary to MOH. This is the most beefed-up MOH we have ever had in the 49-year history of the nation.

We now have at the political appointee level one cabinet minister, one senior minister of state, one minister of state and one parliamentary secretary. That’s four politicians. At the senior management level, we have two permanent secretaries, one DMS, two deputy secretaries and one more deputy secretary –level person running MOH Holdings. That’s six persons at the senior management level.

Altogether that makes ten persons at the highest levels of MOH. Let’s call them the “tua-liap” ten. This number of tua-liaps (big-shots) raises very important questions:

a) How do you find enough rooms for all ten of them plus their personal assistants at the top floor of the College of Medicine Building (COMB)?

b) Who gets the coveted four car-park lots at the back entrance to COMB?

c) Are there enough seats in the MOH Boardroom, and if so, who gets to sit in the front row around the table and who gets kicked to the back row of seats and most importantly of all…

d) Can the foundations of an old building like COMB take the top-heavy MOH line-up?

The appointment of the Second Permanent Secretary to MOH, MG Ng Chee Khern is perhaps the most interesting one in a long time. Firstly, he was formerly the Chief of Air Force and hence Top Gun. Secondly, he was Director of Security and Intelligence Division of MINDEF – that makes him chief spook. A fighter pilot ace and master spy is not to be trifled with. He probably already has a dossier on this Hobbit which is thicker than Gimli’s beard.

But that’s not all, he has written this 29-page masterpiece on staff work in the MINDEF publication POINTER. This is accessible to the public at the URL link below. I urge all MOH staff and restructured hospitals staff to read it. They are also advised to read it while sitting on the toilet bowl because in all likelihood they will be defaecating bricks while they read this seminal work. 2PS (Health) is not only Top Gun and Chief Spook but he is also English Wordsmith, as evidenced by Section 2.2: Using clear, concise and correct language.

But seriously folks, many civil servants have spent a lifetime honing their language skills so that they communicate, confirm and conclude NOTHING in their writings. How can they be asked to use clear, concise and correct language? 2PS(Health) has a better chance with a Wookie or Groot.

Now onto the really serious matter of the day- allegations of overcharging and over-servicing.  Dr Tang Kok Foo’s two letters to the press have raised quite a maelstrom as things go. (After reading 2PS(Health)’s 2009 Pointer article, this Hobbit is inspired to use one big word hopefully correctly – maelstrom).

There are those who protest against Dr Tang’s allegations. They claim that the medical profession is still largely ethical and that respect for patients is the most important guard against unethical behavior. They are right. But they are missing the point – overcharging and over-servicing is indeed on the rise recently. Of course, one can claim that overcharging is very rare except in the most egregious of cases. But this Hobbit would like to introduce a new concept – that of ‘uncomfortable’ charging. There are more and more cases of specialists in the private sector who are charging in a way that makes many in the profession uncomfortable. It may be wrong to label these folks ‘overcharging’ since the guidelines for fees no longer exist. But the quantum charged makes many of us uncomfortable.

But doctors charging uncomfortably are not just the ones to blame. Indeed, private hospital charges are also part of the problem. So this hobbit found the MOH’s letter to the press on 26 Aug 2014 about private hospital charges not coming under the purview of MOH to be lame and disappointing. It is another fishball stick incident in the making. So whose purview does this come under? Do we need a Ministry for Private Health or Private Hospitals to be in charge of this? The Ministry of Health (Public and Private) has a responsibility to keep private healthcare affordable as well. And this begins with costs. If you leave everything to the ‘free’ market without understanding the real forces at work here that drives behaviour, then you will get people bidding $1.28 billion for hospital land, prices of $8000 to 9000 per square foot for clinic suites with only ~65 years left in the lease, charging $10,000 for colonoscopy and fixing of clavicles.

We now even have private hospitals offering rental rebates for doctors renting clinic space from these hospitals. These rebates are directly and mathematically linked to the patient billings they generate for the hospital. Such an arrangement offered by private hospitals obviously encourages over-servicing by participating doctors. Whose purview does this come under?

We cannot afford to wait any longer to fix these problems. We claim to be a medical hub. But already, hundreds of patients from Indonesia are going to Malaysia everyday to get medical treatment. This number is greater than the number coming to Singapore, although Singapore still gets the more complex cases. Many more from Myanmar, Pakistan and Bangladesh are going to India. And if and when Thailand sorts out its political problems, Bangkok will draw many more regional medical patients to its hospitals. Singapore is fast losing its allure as a regional medical hub. If we do nothing, we will certainly lose our hub status in 10 to 20 years’ time.

Every right behaviour starts with the right policies. Not having a purview of certain things means a policy of having no policy about these same things. There are exceptions, but a policy of having no policy seldom engenders the right behavior.

http://www.mindef.gov.sg/content/imindef/publications/pointer/supplements/onstaffwork/_jcr_content/imindefPars/0013/file.res/ON STAFF WORK(L)_280809.pdf

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