SG50 to SG100: Will We Still Be A Medical Hub In 50 Years’ Time?

We are inching closer to the biggest event of the year with each passing day – SG50. SG50 promises to be so big, it’s bigger than the size of the noses of Barbra Streisand, Celine Dion, Barry Manilow and Ben Stiller’s put together. Now that’s BIG.

While we celebrate the country’s 50th birthday in style, many are fretting if Singapore will continue to prosper in the next 50 years. Folks are reflecting on many of the aspects that have made Singapore so far and wondering aloud if the success story can continue. These aspects have been conveniently labeled as SG50+ or SG100 topics. The range of SG50+ orSG100 topics range from the effectiveness of our armed forces to the survival of our hawker food culture.

This hobbit would like to add one more topic to the already wide-ranging list of topics: Will Singapore  continue to be a medical hub in 50 years’ time?

A recent news article has sounded warning bells by saying that we are already losing foreign patients to our regional competitors (The Straits Times: Singapore losing medical tourists to neighbours, May 8).

To be fair, MOH has lately done a lot for primary care and intermediate and long-term care (ILTC). MOH has also done a lot for healthcare funding in terms of the Pioneer Generation Package and Medishield Life. But we are talking about being a medical hub, at least a regional one where patients from Southeast Asia or the whole of Asia come here. With all due respect to my colleagues working in primary care and ILTC sector, foreign patients largely do not come here (or for that matter anywhere else) for good primary care, community hospitals or nursing homes. They go abroad or to a faraway place for general hospital or specialist care. That’s what makes a place a regional medical hub.

To answer the question of Singapore staying as a medical hub, this Hobbit will now look at just three important factors that affect Singapore’s status as a medical hub.

First Aspect: Consistency in Government’s Philosophy and Policies

Make no mistake, the role of the government in ensuring Singapore stays a medical hub cannot be underestimated. The government’s role and impact is especially important in healthcare. It is policy-maker, regulator and a huge provider of healthcare. In fact, it takes up the lion’s share of specialist services offered in the country. The same services that make or break any place being a medical hub. The government’s role in healthcare is much larger than in other sectors such as hospitality and travel, manufacturing or shipping.

To ensure success in any sector and not just healthcare, consistency in policies is very important so that investors and quality people can invest and devote money, time and effort into a certain sector.

For example, when people invest hundreds of millions or billions into the hospitality industry by building and running hotels, tourist attractions, they must have the confidence that government policies and regulations are transparent and consistent. We may tweak and update these policies and regulations, but the overarching philosophy and commitment must be firm and long-term. This is what makes MNCs invest huge amounts of money into Singapore for the long-term, such as Shell or Esso in the oil and petrochemical sector, or Rolls Royce in the aerospace industry, just to name a few.

For healthcare, things were pretty consistent in the 10 years or so following the publishing of the Affordable Health Care White Paper in 1993. But since then, the government’s position on many healthcare issues and especially on that of Singapore as a medical hub,has been rather erratic. This is exemplified by the government, in particular the MOH, changing its stance towards the role of market forces in healthcare.Should market forces be left alone, encouraged, contained or denied? No one is any the wiser. In the aforesaid White Paper, it was stated clearly that healthcare is an example of market failure and the supplier-induced consumption is to be prevented. Hence healthcare cannot be left to the influence of unbridled market forces.

Another example how market forces must be curbed is that of land released by the government for private hospital development. For close to 30 years since the seventies, there was no land released. Then about 8 years ago, not one but two plots were released (Farrer Park and Novena). Then nothing again. The current thinking appears to be that building more private hospitals will lead to exodus of talent from the public to the private sector. So not releasing land is a way of reining in market forces and protecting the public sector. Going forward, no one really knows when the next plot will be released. Is it next year or 2035? Because of this uncertainty, it is no surprise that Singapore holds the distinction for the most expensive private hospital in the world (Novena: ~1.28 Billion). This is unsurprising given the fact that when a plot is made available, interested parties will sell their grandmothers to try and secure the site, because no one knows when another site will be made available.

Then again, the government can be completely pro-market. Just look at how MOH did nothing to stop the Competition Commission of Singapore from outlawing SMA’s Guidelines of Fees (GOF). TheGuidelines of Fees is a way of controlling costs but the government saw it fit to kill the GOF and let market forces run amok in doctors’ charging. Only in the most egregious examples is excessive charging deemed overcharging and unethical (by the Courts).

It would appear from the above that no one really knows what is the consistent policy position with respect to market forces in healthcare. Maybe the consistent position is that there is no consistent position and everything is situational.

Another example is our approach to foreign patients. Do we want them or do we not want them? Every real professional in healthcare knows that a local population of 5M cannot create a good regional medical hub. There just isn’t enough workload to create excellence. Excellence in clinical medicine comes with practice. And practice comes from workload. We get excellent because we see the most difficult cases out of a 250 million population (like Indonesia), not a 5 million population (like Singapore).

About 12 to 15 years ago, there was much talk about attracting foreign patients not just to private hospitals but public ones as well. Singapore Medicine was set up to much fanfare. Almost all public hospitals set up an International Medical Services (IMC) office or department.Now Singapore Medicine is hiding in some corner like an embarrassing wart,largely forgotten or trying to be forgotten. Singapore Medicine is a prime example of our inconsistent approach to our philosophy towards healthcare.

The usual counterargument is that we should avoid the big, bad monster called ‘demonstration effect’ in which the visibility of foreign patients receiving high-end (read: expensive) healthcare will spur voters to demand for the same to be provided for the masses at highly subsidised rates.

It is interesting to note that no one worries about the demonstration effect of the many foreigners in Ferraris,Lamborghinis, Porsches, Bentleys cruising down our roads, or the sheer opulence of our Integrated Resorts and the villas in Sentosa Cove, but we always worry about demonstration effect in healthcare. First of all, we must realise that no one, rich or poor, wants to be in a hospital if they can help it, unlike say,sitting in a Bentley. Demonstration effect in healthcare is way over-rated, but policy makers seem to be highly sensitive if not fearful of it. But they are not fearful of all the foreigners (whether tourists or residents) displaying extravagant consumption behavior in other areas. The Hobbit finds this rather incongruous.

Second Aspect: Moderation

It is no secret that along with consistency, moderation is another important characteristic that good policy-making and implementation should have.

A good example of this is that of defence. There is both consistency and moderation. Government’s commitment to defense has always been around 5%of GDP. It is moderate and it is consistent. Procurement decisions are prudent and staged or phased over years in a smooth fashion.

In the areas of foreign affairs too, we are moderate. We don’t make enemies and agitate or aggravate the situation unless absolutely necessary.

But for healthcare, there is no such moderation or consistency. We can decide to not build any public hospital for ten years from the mid- or late-nineties and then go on a building blitz of three to four general hospitals in the next ten.

A more mundane example would be the subject of medical manpower. At one time, the government thought having more doctors was a bad idea. So medical student intake was curbed. In fact, MOH thought it had too many doctors, and in the early nineties, quite a few doctors were give nearly release from their 5-year service bonds. Now it seems we never have enough doctors and we are looking to producing 500 to 600 graduates locally in the near future. And that excludes the many Singaporeans we have studying medicine overseas and the hundreds if not thousands of foreign doctors we have brought in from overseas in the last ten years.

This Hobbit fears that we are swinging between famine and feast moods like some anorexic-bulimic bipolar patient.

A more difficult if not contentious example is that of clinical quality and patient safety. Everyone wants 100% safety and tip-top quality. But let us be frank, this approach comes with great cost. It is widely known in the IT industry that if you want a system availability of99.9% instead of 99%, the additional 0.9% that you want may often come at double the cost. This is the law of diminishing returns demonstrated in exponential terms. Healthcare is no different. We are putting into place so many practices and systems to ensure that our practice is 100% fool-proof safe that costs have soared. Many things that were once done by junior staff are now taken up by senior staff in the name of quality and patient safety. This includes simple things like signing of a death certificate to taking consent for an OGD. The result is that we need more and more senior staff (read:expensive). This is because the authorities and system do not have the courage to take some risks and back the senior staff that in turn back the junior staff up. Certain SMC rulings do not help but aggravate the situation as well. In the process, we have removed moderation from our mindset and replaced it with extremist clinical quality policies and practices. Of course,we do not want to continue ‘cowboy’ practices but patient safety does not mean “thou shalt not take any risk”. Some risk is acceptable and necessary in the pursuit of clinical quality and patient safety. It is part of the approach of moderation. If not, no number of medical and nursing staff will be enough and costs will shoot through the roof.

There ‘no-risk’ extremist approach is most often seen in healthcare regulation. Examples include the widespread unhappiness from the original attempt to regulate medical equipment and disposables down to the nitty-gritty.

Another example is in the area of Assisted Reproduction (AR). In the wake of a sperm mix-up case a few years ago,regulations were reflexively tightened to control these centres to the point where many new scientific advances in this area are still disallowed inSingapore. But science moves on even if our regulation is archaic. As a result,many of our local AR doctors now actually refer patients to neighboring countries to receive these latest investigation and treatment modalities. This is as ironic as it gets.

Regulation involves risk. This hobbit has said so before and will say this again, regulators that cannot accept risk do not understand the nature of healthcare regulation, especially in the regulation of clinical practice.

Another most glaring example is that of the residency system. It is on-paper and theoretically a good system that is supposed to achieve the highest quality. But seriously, we cannot afford it.The limitation to hours by residents and the direct supervision comes at tremendous system costs. That is why you will see that the number of doctors have increased tremendously yet queues are getting longer in our public hospitals. The residency system is the main reason why productivity of our doctors is dropping like a rock, even though this hobbit acknowledges that with an ageing population, there are more patients with complicated medical problems.All this while our Prime Minister and many cabinet ministers are emphasising that good economic growth can only come by increasing productivity since population and foreign manpower growth will slow down going forward.

But since we are on to the subject of residency, let us move on to the third and equally important aspect:

Third Aspect: Relationships

Confucius described society as being made up of relationships. The five most important being: Ruler and Subject; Father and Son; Husband and Wife; That between Brothers, That between Friends.

The principle of relationships apply to healthcare as well. It is just that there are certain relationships that are peculiar to healthcare; the most important being that of the doctor-patient relationship of course. Other very important and special healthcare relationships include the teacher-apprentice relationship and the peer-junior doctor relationship (i.e. relationship between junior doctors).

The doctor-patient relationship is under threat from the rapid legalisation of medical ethics. Defensive medicine is already here and getting more and more pervasive. Over-commercialisation of medicine especially in the areas of medical advertising, managed care and aesthetic medicine lead to the erosion of the traditional doctor-patient relationship as well. This is not peculiar to Singapore but certainly we do not seem to appear to want to fight the currents. In many areas, we are even promoting it, especially in the area of medical advertising and doctor’s charging.

Medical training has always been described as an apprenticeship. The balance of power has always been heavily in favour of the master in the relationship and training is tough. In return, the master takes it upon himself to take care of the apprentice in a holistic way, almost like that of a parent-child relationship. Complementary to the master-apprentice relationship is the relationship between junior doctors, especially between that of trainees (i.e. residents) and non-trainees.

The trainee has always been the junior doctor that works harder, longer hours and hopefully is smarter than the other junior doctors. This is how the trainee doctor justifies his privileged training position versus other junior doctors.

But these traditional relationships are being attacked by the residency system. The resident now works lesser hours and sees fewer patients than the non-residents. He gets protected time and limits to workloads. This incredulous position is enshrined in the residency system.The apprentice is now the master because the teacher or supervisor is now bound by so many rules and requirements that the resident has more leverage over the master and not the other way around.

When relationships are turned topsy-turvy,the community suffers. In this case, the healthcare community- both professionals and patients suffer. Relationships take a long time to build. They can be destroyed rather quickly and take even a longer time to rebuild, if it is possible to rebuild at all.

Conclusion

Let us now go back 10 years to 2005. In 2005, Singapore was already a medical hub. We have our great academic centres such as SGH/Outram Campus and NUHS. We also have our private hospitals such as Mount Elizabeth and Gleneagles that attracted many foreign patients. We were recovering well from the SARS Outbreak of 2003. We could have extended our lead as a medical hub over our competitors by deploying more resources and having the political will to develop Singapore as medical hub.

In 2005, Singapore already had the greatest concentration of medical talent and the best facilities in the best region. For example, Outram campus (SGH and the national centres) probably already provided direct employment to about almost 10,000 people then.

In contrast, in 2005, Singapore had practically zero talent in casino management and zero facilities for gaming other than the slot machines located in not-for-profit clubs. (Okay, we also have the Turf Club and our various 4D and Toto outlets in 2005).

In other words, we were nobodies in the gaming world while Singapore was already an established and respected medical hub in 2005.

But 2005 was also the year that Singapore decided to develop two Integrated Resorts (IRs). Huge tracts of land were set aside for the IRs. The site that is now Marina Bay Sands was priced at only $1.28B (same as Novena).

Today, our medical hub status is slowing being eroded by our competitors, such as Malaysia and Thailand. Malaysia sees more foreign patients than Singapore. Our private hospital services are very expensive, which is no surprise given the very expensive hospital land costs and the outlawing of GOF.

On the other hand, since opening in 2010,the two IRs now boast combined gambling revenues that are almost as huge as the entire Las Vegas gambling strip. The two IRs provide direct employment to 22,000 people and if you count indirect employment, about 40,000 people, according to figures from the Ministry of Trade and Industry website.

But as we all know, IRs come with significant and terrible social costs. Moneylending, whether legal or illegal,have grown by a rapid pace in the last five years. We do not have readily data on suicides, family breakups, bankruptcies etc that arise from problem gambling but we can be quite sure they have grown significantly as a result. We are paying these costs everyday.

Wouldn’t it be better if instead of having IRs developed from scratch, we went forward and leveraged on our already existing medical hub-advantage and developed one or two Integrated Medical Centres (IMCs) like Mayo Clinic in 2005? The employment opportunities provided by a medical hub will be no less than an IR (about 10,000 to 15,000 people) and a medical hub has far, far less negative externalities than an IR.

But we made our choices 10 years ago and now we have to live with the consequences. We are now a key gaming hub and a declining medical hub.

Will we learn our lessons and make the right choices over the next 50 years? This hobbit is not optimistic.

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