May Musings

As this hobbit writes this column, the world is agog with stories of cyber-attacks crippling services and companies. One of the worst hit is the British NHS. How important is the NHS? If you would be let to believe, the British, in a poll a few years back consider the creation of NHS to be more important than the defeat of Germany in World War 2. So crippling the NHS is a big deal.

The underlying problem is really that of over-optimisation. In a bid to optimise the operations of the NHS, patient records were all made electronic and centralised. That made it ripe for a mighty cyber-attack. It’s the phenomenon of “optimisation to vulnerability”. One cannot escape this phenomenon. It is a trade-off. The question is whether society is waiting to make this trade-off. In Singapore, this question has not been asked. At least not in the arena of a national electronic medical record.

The techies and IT guys do not usually mention this trade-off. They just want to digitalise everything and put it on the cloud, and everyone lives happily ever after. Well, life is not like that, as the UK and NHS are now finding out.

Also, IT is unique in that the IT guys who designed and then operate the system or software are seldom if ever held liable for cyber-attacks. This is in contrast to other disciplines or commercial activity. A company can be sued for designing or manufacturing a car badly or even just a car airbag badly. In contrast, no one has sued an IT firm for lousy software that is easily attacked and crippled.

So to the guys who are rushing to promote some national software or clinical records under the banner of optimisation of healthcare, let the current NHS incident be a warning to them. Especially to the policy wonks who do not really understand what’s happening on the ground. There is some merit still to having dispersed repositories of medical records as a risk management tool as opposed to putting everything in one big virtual cloud. Centralise (“Cloud-ize”?), optimise and digitize comes with risk and consequences. And the more you do so, the greater the risk and consequences.

In the meantime, horror stories of newly minted specialists unable to secure jobs continue to come in to Hobbit Central. Many have been told they will be offered contracts to continue as resident physicians with terms no better than what senior residents get even though they are now fully qualified and registered by the state as Specialists.

On top of that, in response to the glut of residents exiting specialist training, many hospitals are cutting back drastically on the number of new residents they are taking in. This hobbit was told in a certain discipline, the number of residency places being offered has gone down from 12 a few years ago to now 1 or 2 residents.

Obviously, this boom and bust phenomenon is not making anyone happy. The older exiting residents who cannot get a decent Associate Consultant post or the house officers and junior medical officers seeking specialist training are equally miserable and frustrated.

Some disciplines fare better because they were “disobedient” in the past and refused to accept more residents then they could commit jobs to. Others are really suffering now because they listened to the call to suddenly take in many more residents without thinking through the long term downstream effects. In retrospect, unquestioned obedience isn’t such a good thing after all.

The folks who put in place the policy to open up residency places several years ago are still around, just hiding in some corner. They obviously did not read what Milton Friedman said about money supply. A smooth, steady and slow expansion of money supply is key to generating steady and sustainable growth. Printing more money indiscriminately and quickly just exacerbates the boom and bust cycle and creates much misery later. This hobbit thinks the same principles of a “Monetarist” policy should apply in manpower supply planning. We are obviously seeing the similar poor outcomes now due to the irresponsible and rapid expansion of residency places several years ago.

In the longer run, we should even question not just residency places but the actual number of doctors we are producing. The three local medical schools produce about 600 graduates a year. Another 100 to 200 go overseas for medical studies. While no one owes anyone a living, we should still give priority to attracting our Singaporeans back to practice even though they studied overseas. That’s ~750 medical graduates Singapore has to absorb a year.

Singapore has about 35,000 births in a good year. In other words, every year, we have a cohort of 35,000 Singaporeans. Let’s multiply this number by 2 to include Permanent Residents, foreign workers and even tourists. So we have a “modified” cohort of 70,000. Yes, the population is ageing and we need more doctors. But we are also a small country that does not suffer from the inefficiencies of geographical factors such as providing care in rural and remote areas etc. Many developed countries also have ageing or aged population demographics, so a cohort size of 70,000 is about right.

Most developed countries have (practicing) doctor to patient ratios of between 1:250 to 1:400. UK – 1:369; Netherlands – 1:342; France – 1:305; Denmark – 1:287, Sweden – 1:250, Australia – 1:255; USA – 1:400.

Based on a cohort size of 70,000, if we adopt a generous target of 1:250, we only need to produce or recruit 280 doctors a year in the steady state ONCE we have reached the target of 1:250. If our target is 1:400, then we need even fewer – 175 doctors a year once the target has been attained to serve a cohort of size of 70,000. Yet, we are now producing 750 graduates a year (600+150)

Singapore currently has a doctor-patient ratio of 1:430 (MOH data). If we only include practicing doctors, the ratio is probably closer to 1:470, assuming 1 in 10 doctors are employed in non-practising roles or retired but still registered etc. Again, let us be generous here even though the MOH website states that only about 5% or 600 doctors are not in active practice.

At the rate we are going, we will reach the low target of 1:400 in about 4 to 5 years and maybe the high target of 1:250 in 10 to 15 years, assuming the three medical schools keep producing 600 graduate a year and 150 Singaporeans go overseas to study medicine and return to its shores.

When we are at steady state, what do we do with the 3 medical schools? Even if we take the draconian approach that we do not take in anybody from overseas (even if they are Singaporeans), the 3 medical schools need only produce a total of 175 to 280 medical graduates a year.

To have some economies of scale and to maintain quality, an undergraduate school should produce ideally between 150 to 200 a year and a postgraduate school should have a cohort of about 100.

What are the choices then when we have attained our desired doctor-patient ratio (whether 1: 250 or 1:400 or somewhere in between)?

This would imply one or more of the following

1. We will certainly have to cut down on class sizes in the three medical schools. We may even have to close one medical school
2. We can make medical education an “export” business, which is what some countries do, such as Ireland. But our cost structures are hardly competitive. If we remove the subsidies for the medical schools, the full cost of medical education in Singapore is probably more expensive than UK or Australia.
3. There will be a serious and growing oversupply of doctors locally and all its attendant negative consequences.
4. Medical graduates cannot be trained properly or secure good clinical jobs.

Actually we need to look no further than our neighbour Malaysia. There are now at least 32 medical schools that have set up shop in Malaysia and Malaysians can also get their degrees from overseas, in traditional places such as India or even as far away as in Ukraine.

There are so many medical graduates that they cannot secure house officer positions in government hospitals. There is a waiting list for positions. And even when you do get a house officer job, there are often so many of house officers that each house officer is given just two or three beds to attend to. This is hardly a recipe for good training of junior doctors.

I hope someone in power is thinking about these medical manpower issues now and making the correct policy adjustments and plans in anticipation of the future. The future is often nearer than we think…