The Hobbit Awakens

 

 

Regular readers of this column will realise that this Hobbit has been silent for more than 2 months. Yes, this Hobbit has been busy with some personal business, which includes trying to tattoo BB-8 on his hairy chest, getting to get Mark Hammil to lose weight and renewing the SMC Practicing Certificate.

Regular readers will also notice that this column is on a new platform as a blog. The old Facebook account has been deactivated. This is because Facebook now requires that this Hobbit provides documentation that this Hobbit is this Hobbit. Hobbits do not have birth certificates or NRIC! Do you think I would have had to climb and crawl my way to Mount Doom if I owned a Driver’s License? I suspect Facebook is now advised or run by evil management consultants from McKinky or Boston Chowder Group, who are in turn spiritually enslaved by Sauron.

Old articles written in the Facebook-period have also been reproduced in this blog.

Anyway, this Hobbit has awakened after two months because another shorty also awakened in the last couple of days. I am of course talking about R2D2. And I have got the map to locate that something rarer than the last Jedi – the last general medicine physician in Singapore – Chee Yam Cheng. Prof Chee is apparently hiding in the Irrawaddy System because he feels responsible for not taking up the offer to be DMS 12 years ago which led to the beginning of the Dark Ages, otherwise known as the Residency System, which is more toxic than The Dagobah and Jakku Systems combined.

Speaking of Practising Certificate renewal, SMC has done it again. Somehow the guys who plan and operate this organisation has a wonderful gift of irritating doctors. Their natural propensity to irritate doctors is akin to Rey’s attunement to the Force. Only now, do I realise the power of the SMC side. I now understand that the expiry date on my practicing certificate is a source of distraction. The really important factoid is that you must apply to renew your practicing certificate three months before the current practicing certificate expires. In the past, this is an automatic process once you have met the CME requirements, but somehow this time round, having met the CME requirements, you still have to apply for its renewal online. If you apply late, (i.e. less than 3 months before the current practicing certificate expires), there is a late renewal fee of $80 payable.

What this means is that:

• You don’t have 24 months to obtain your 50 CME points, you have at most 21 months, if you want to avoid paying another $80
• Even if you have the 50 CME months in record quick time, you still have to apply for the renewal, even when say, you have put your SMC practicing certificate fee on GIRO (automatic deduction from bank to SMC) at least 3 months before the current certificate expires.

These guys are truly evil. They make Kylo Ren look as lame as an Ewok (OK, I gotta admit, Kylo Ren, aka Adam Driver unmasked is lame. Period. He looks like a younger version of Friends’ David Schwimmer, aka Ross Geller, another super lame guy).

Next on the list is the recently announced Committee on Future Economy. This is the biggest thing to hit Singapore since Singapore Conversation, Remaking Singapore and the launch of McDonald’s Hello Kitty toys. 30 of the most important persons will advise the government on how and where our economy should be heading over in the next 5 to 10 years. It was reported in The Straits Times that this Committee would tackle six key areas

• Future growth industries and markets
• Corporate capabilities and innovation
• Jobs and skills
• Urban development and infrastructure
• Connectivity
• How did the Millennium Falcon do the Kessel Run in 12 parsecs?

There are businessmen, management consultants, lawyers, unionists, bankers and fund management professionals etc in this Committee but NO representation from healthcare, much less doctors. The finance sector gets representation in the form of 2 bankers and 4 fund managers; manufacturing gets five representatives. Healthcare and healthcare professionals? One Big Zero.

That shows you more or less what the folks in power think of healthcare as a key plank in the future economy. This is more baffling if you consider that healthcare is one of the key hubs of Singapore now. Healthcare is where Singapore still enjoys a competitive advantage over other regional players. On the other hand, what are the competitive advantages that Singapore has in manufacturing which would justify five representatives? Instead of trying to leverage and improve on existing strengths in healthcare, we are trying to flog the ailing and ageing horse of manufacturing….Seriously folks, in Japan and certain parts of Northern China, they just eat the horse and move on.

It would appear that current thinking on healthcare has regressed back to the pre-90s thinking that healthcare is solely a social/domestic issue and a cost to society, rather than an economic driver that creates jobs and brings in foreign exchange. It’s Back to the Future all over again.

Another sad development is that of the recent news that Peacehaven’s plans for a different model for a nursing home that caters to demented patients have been shelved because MOH does not support it. (The Straits Times, 21 Dec 2015).

This is a sad development because it appears that the folks who decide on government subsidy policies cannot or are unwilling to accept the medical fact that patients with dementia who need to be put in a home are very different from the average nursing home patient.

Dementia patients have more complex emotional issues and needs than say the stroked-out patient- bed- or wheelchair- bound and on tube feeding and can barely talk, let alone socialise. Rooms with one or two residents will do wonders for dementia patients’ self-esteem. This is borne out time and again by many studies. But of course, bean counters will not understand this, or accept this. In this area, we are definitely NOT first-world. Instead, we choose to build and fund general hospitals that look like a holiday resort hotel in Bali (First-world plus). If it is truly a matter of operating cost (It cannot be capital cost, because the affected NGOs had agreed to fund $10M out of $15M that was needed to build the new home), then why not remove the en-suite bathrooms and toilets, but at least give every one or two patients four walls for more privacy (and self-esteem) instead of the large cubicles containing up to eight or even ten patients?

Our approach to healthcare funding has been concretized into dogma. And the dogma involve the following:

• Funding must be tied to bed-class. The level of funding is inversely proportional to the physical comforts of the class so as to prevent people taking advantage (i.e. moral hazard or ‘buffet syndrome’) of the subsidies. Even though we already have means-testing in place which already addresses the ‘buffet syndrome’ issue.
• General hospitals and acute care enjoy generous funding and funding policies because they are expensive to run. On the other hand, stringent policies govern funding of intermediate and long-term care (ILTC) services. This is strange because ILTC services are cheap to run in comparison with general hospitals and the potential savings that can be achieved are very little even if you try to squeeze blood out of the ILTC stone. On the other hand, the generous buffet in acute care and general hospitals continues. If we are really trying to contain healthcare costs, one should try to contain costs at the expensive end, not the cheap end.

Then there is this half-baked letter in The Straits Times Forum on Christmas Day by a certain Francis Cheng that completely misses the point. It is not a premium service. It is a service for dementia patients that is very different from normal nursing home patients.

Even if one concedes the point that it is a ‘premium’ service, one must ask, are we building nursing homes based on the past or based on what we expect in the future? What is the definition of ‘premium’? What is yesterday’s premium will become tomorrow’s ‘basic’. 25 years ago, air-conditioning in polyclinic was premium, now it is basic.

Will Singaporeans (even poor ones) accept staying in a large room with 7 other residents in 10 to 20 years’ time? It is true that most poor Singaporeans today in their 70s and 80s accept this arrangement. But people who are in their 50s and 60s may not accept this when they require nursing home services in 20 years’ time. Are we going to reconfigure and rebuild all these nursing homes that we are building now to cater to anticipated needs and demand?

It is also superficial to call a one or two-bedder ‘premium’ across the board from a general hospital to a nursing home. The two are very different animals. The average acute hospital inpatient stays in the hospital for about a week. Hence, the majority of Singaporeans may accept B2 and C class arrangements with six to eight patients per cubicle with little privacy given the short period of stay. But nursing home patients often spend one to two if not three years in a home. And the period is probably longer for demented patients. Will the majority of Singaporeans accept living in a large room for one to three years with seven other residents in 10 to 20 years’ time? These are hard questions policy makers and bean counters have to ask now and not kick the can down the road. Times change and we must change with them.

Finally, we come to the biggest issue of the last three months, the ‘Starkiller’ issue. Yup. The Hepatitis C outbreak in SGH in which several patients died. It is a tragedy, plain and simple. Heads will roll and blood will be let (That’s what certain committees are eventually meant to do, implied or otherwise). Many heads and a lot of blood. But it would be a mistake to believe that after forming high power committees and blood letting, such an event would not happen again. It will happen, and most likely it will still be a large hospital like SGH. Especially SGH. Because for some strange reason, after clustering and reclustering and building of hospital after hospital, the majority of immune-compromised inpatients in Singapore are still served in SGH: the cancer, renal and haematology patients. This is not to absolve SGH staff’s responsibility in this tragedy, especially in the delay in informing higher authority and the infection control lapses, and those that if necessary, have to be reprimanded, punished or even removed, should be.

But it remains a fact that SGH is the most dangerous hospital in Singapore by virtue of its workload and casemix of patients. It is said that the Outram campus has a one-third market share of all public hospitals’ workload and handles more than 50% of the aforesaid immune compromised inpatients in Singapore. Having a SWAT team may help to quicken the response and escalation, but the SWAT team will not prevent outbreaks.

It is time that we spread some of this risk to other public hospitals. It is never wise to put all or in this case, most of your eggs in the same basket. Which is what the bad guys in Star Wars never learn, from Episodes 4 to 7. You shouldn’t be building huge battle-station after battle-station than can be blown up by small one-man starfighters; spread the risk, dude…..

Enough said for now. Time for this Hobbit to go on his next quest, which is to locate the one thing now most heavily sought after by the evil First Order – a plate of grass carp raw fish….(I confess: I am actually going to play with my remote-controlled BB8 now)

Here’s to a better 2016 for the medical profession.