Singaporean Efficiency

On 17 Nov 22, while referring to the NHS (National Health Service), the British Chancellor of the Exchequer (a fancy UK name for Finance Minister) Jeremy Hunt, said in the House of Commons (a fancy name for Lower House of Parliament), “We want Scandinavian quality alongside Singaporean efficiency, both better outcomes for citizens and better value for taxpayers.”…(Ref: https://www.bbc.com/news/av/uk-politics-63663033)

Coming from our colonial masters, that’s quite an endorsement of what we do now. It wasn’t so long ago that they started a medical school in Singapore called the King Edward VII (KEVII) College of Medicine, which only conferred a qualification called the Licentiate of Medicine and Surgery (LMS) to the natives (i.e. us). Those armed with an LMS could practise as “Assistant Physicians”, to the physicians (i.e. the Europeans/colonial masters) but could never apply to take exams that led to one being recognised as proper specialists, such as MRCP and FRCS. The highest degrees they could attain were the LRCP and MRCS, which were not recognised as specialist qualifications. In other words, a hard ceiling was put in place for natives holding a LMS in that they could never specialise. It was only a few years after World War 2 ended that the College started conferring MBBS.

By the way, the LMS remains a recognised qualification under the Medical Registration Act and one can practise in Singapore with just an LMS issued by the KEVII College of Medicine. This hobbit just wonders if there are still any doctors alive today with LMS.

Enough of history. What is efficiency? At the heart of it, efficiency implies a healthy ratio between input and output. An efficient system means one comparatively puts in few inputs of resources (time, people, money etc) and gets a lot of output. In healthcare, the concept of efficiency has evolved to outcomes as well. In layman terms, efficiency can be simplistically described as getting a bigger bang for the buck.

But seriously, are we as efficient as Mr Hunt thinks? This Hobbit has serious doubts. And even if we are efficient now, it is obvious that this efficiency is declining. If it were not, our MOH budget would not be growing quite so fast and the growth trajectory has been described as “unsustainable” by Finance Minister Lawrence Wong in his Budget Speech this year.

For the current financial year, MOH has been allocated the largest budget of all ministries, surpassing that of even MINDEF and MOE. True, there are a few billions in there budgeted for Covid-19, but even if we strip that out, MOH probably still has the second largest budget in government today.

With this large and fast-growing input of money, are we getting a lot more output and more importantly, more and better outcomes? It is probably the realisation that we are not that has led MOH to implement Healthier SG.

But will  Healthier SG improve the efficiency of the healthcare system by placing emphasis on preventive medicine and the family physician? The simple answer is “yes”. But the improvements will be limited because there are other powerful forces at play that drag down efficiency.

First, there is the Americanization of Singapore healthcare that has taken place in the last 15 years or so. America has probably the most inefficient healthcare system in the world, spending a whopping 18% of GDP on healthcare while its population has health outcomes that are inferior to many first world countries. When we unthinkingly introduced stuff like ACGME-I Residency and JCI into our healthcare system, we are really aping a country that spends 18% of GDP when we only spend about 5% GDP on healthcare.

One ENT surgeon recently remarked “Latest example of how JCI increases costs – we have been rolling our own shoulder roll in OT for decades. Last week, a young American JCI surveyor came and said “Oh, this does not meet the required standard and will not pass safety and infection control guidelines. You should buy proper shoulder rolls and replace them regularly”. Are we supposed to follow her advice? Why should we?? Thanks for contributing to escalating healthcare costs. Let’s become USA”.

Let’s also look at the ACGME-I Residency that some geniuses decreed must be implemented some years ago. Has that led to better specialists being produced? If so, then how come most private hospitals have now put in place a requirement that a specialist must have spent at least 5 years in a restructured hospital as a specialist, of which 3 must have been as consultant, before he or she is given admission rights in the private hospital? In other words, a specialist must now have spent at least 2 years as Associate Consultant and 3 as Consultant before this specialist is given practising rights. This is the market recognising that despite putting in more resources to implement American-style residency, the product is not of the same quality of yesteryear.  The American Residency system may appear to be more efficient superficially by cutting down the number of years needed to produce a state-registered specialist, but it is not.

Moving on from Americanisation, we come to the more difficult issue of culture and risk management. The system cannot get more efficient when tasks that were previously done by junior staff are now pushed to the more senior staff. This is only logical because a senior staff costs more than a junior staff. Old coots like us have gone through the times when a 3^rd year registrar can perform a gastrectomy by himself. Now I am not so sure if a “more senior” 2^nd year Associate Consultant can do that. Gone are the days when a Medical Officer can perform an appendicectomy unsupervised. Of course, detractors will say, well, times have changed and the public now demand better care etc. Maybe. Let’s take a simpler example then. Many years ago, a house officer can sign a death certificate, but now only a medical officer can. Yes, there are legal implications of certifying death. But seriously, other than medico-legal implications, how harmful can that be? It is about filling a form correctly and after all, the patient has passed on. And since house officers only practise in hospitals, the unsure house officer can always consult someone more senior when certifying death.

It is all about the underlying culture of risk. Today, the risk appetite is much lower than in the past, even for honest mistakes. And the solution is always to escalate the work upwards to address this. In the world of bureaucracy, there is this concept of “title inflation” where affairs that were handled by a junior staff were now handled by a person with a bigger title (and more expensive). So in effect, the job responsibilities of say, a “Director” today were similar to that of an “Assistant Director” 15 years ago. This will also invariably lead to the appointment of many more “Directors” and higher costs. The same concept can also be applied to our public hospitals. This hobbit is told that this does not only happen to the medical profession but to nursing and allied health professions too. What was done by a healthcare attendant (aka “Amah”) is now done by an enrolled nurse, and what was previously done by an enrolled nurse often has to be done by a staff nurse now and so on.

Have our junior professionals become stupider over the years? Of course not! They are better trained, better qualified and better paid, yet the work keeps escalating upwards. Is it the fault of these younger people? This hobbit thinks not. This phenomenon is a systematic and reflex response that takes place in a culture that is intolerant of any mistake.

When a mistake is made, in order to pre-empt similar mistakes from occurring, the usual and reflex solution is – get the more senior person to do it instead. This leads to increasing costs (and decreasing efficiency) and less job satisfaction and poorer training for the junior staff. And worse, often, all this is done in the name of “patient safety”. When “patient safety” is mentioned, many administrators go into brain freeze and go for the “escalate upwards” option.

This does not mean that we want to mindlessly pile more and more work on junior staff so as to ruthlessly raise the efficiency of the system. Rather we should be looking at giving back the meaningful stuff that junior staff used to do years ago to today’s junior staff and removing the work that is of low value. To do this, there must be a culture of accepting honest mistakes made by junior staff. It starts from the very top and then it cascades down. The “system” must provide political cover to the hospitals, and in turn, the hospital management must provide cover for the clinical departments etc so that a healthier culture can be inculcated down the line.

A risk-free environment seems laudable, but it comes at tremendous cost. This is a difficult thing to say, but there needs to be an acceptable trade-off between risk and cost if we are to run an efficient healthcare system.

If we are unable to accept any trade-off, then the hard truth is efficiency of our healthcare system will continue to decline even though we put in more and more inputs of manpower, time and money.