The Pioneer Generation Package (PGP) was announced to much fanfare last month. There are several notable features to this package.

1.    First of all, it applies to anyone born in Singapore before 1950. Which means Chee Yam Cheng (~MBBS 73, ~65 years old) just makes the cut but Sonny Wang may not (~MBBS 74, ~64). Life is tough.

2.    Secondly, it’s BIG. $8,000,000,000. There are NINE zeroes in there. And guess what, it is funded from 50% of the nett investment income from our reserves of just ONE year. This is very significant. It shows that our reserves are so BIG that just half of the investment income of only ONE year can fund the healthcare needs of 450,000 elderly people for many, many years. Next year and every year, we will have another 7 to 8 billion dollars of investment income that we can use to fund other things, such as my concert ticket to watch the Fleetwood Mac concert and a MRT line that won’t break down every other week.

3.    Thirdly, there is no means test and everyone as defined to be in the age-group of the Pioneer Generation automatically qualifies without filling a form. This is so counter-intuitive to the government and the civil service that this Hobbit suspects some guys in there are getting seizures just from seeing this get implemented. Trust me, there are civil servants who have sworn an oath on the souls of their grandchildren that they will NOT give a cent to anyone unless a form is filled that demand details that even your priest does not want to know during confession.

4.    Fourthly, the 8 billion bucks is supposed to pay for all the people (~450,000) for the rest of their lives until they pass on. I hope the money will last that long.

There are a few things happening on the horizon that suggest that well, $8,000,000,000 may not be enough.

The first thing is life expectancy. People are living longer even as we speak. Life expectancy is a moving target. As we live longer, we need more care.

This is compounded by doctors (yes, we are the main culprits) practising expensive medicine. Some say that the most expensive medical instrument ever invented is the doctor’s pen. Doctors are the main culprits and also the main victims. Doctors are forced to practise expensive medicine from two forces. The first force is the medical litigation climate. There is a climate of fear developed over the last few years. No one wants to be caught out so more and more doctors practise defensive medicine. No one wants to appear before SMC. Even when the complaints committee and disciplinary tribunal proclaim you innocent, the patient can still appeal to the Minister for Health for a second bite of the cherry. The Minister can, presumably on the advice of some enlightened people, ask SMC to reopen the case, with no reason or rationale given. This hobbit knows of several doctors who have been royally punished in this way. The entire process of why a case is reopened in SMC is opaque and traumatic to the doctor concerned, even if the doctor is not found to be guilty in the end. So as the saying goes:- “Only the paranoid survive”. We cannot blame doctors for practicing defensive medicine if regulators commit actions and decisions that promote this behavior, inadvertently or otherwise.And of course, costs go up. And this hobbit thinks that medical litigation will get more and more common if our legal system allows contingency fees (being discussed now, i.e. paying the lawyers only when he wins). This may encourage patients who think they are aggrieved to more easily sue doctors. There is nothing the medical profession can do if this comes about except to spend more on medical indemnity. As the experience of other countries has shown, this will be largely borne by the patients or their payers.

The second force is how we train our doctors. I.e. the American ACGME-I way. We are fragmenting our system more and more. Do you know that under the current Singapore ACGME-I system, general surgery residents do NOT need to know how to perform gastroscopies and colonoscopies?!?!?! Yes, don’t fall off your chair. In future, general surgeons may not know how to do scopes as they are not required to know them before they are signed off as trained and qualified surgeons. Some sponsoring institutions do mandate that general surgery residents learn how to do scopes, but not all do and its up to the institution to decide. This is because in America, general surgeons usually don’t do scopes, the gastroenterologists do. That means another specialist is involved (more cost) when in the past, only one was needed. This is but one such example.

Another training issue is the workloads our younger doctors are getting used to as they are being trained. A recent conversation with a Head of Department in a restructured hospital is telling: “When I was young, I saw 30 to 40 patients in four hours or a half day’s work. Now that I am older, I cannot keep up this pace. Also, I see more complicated cases referred by my colleagues, so I slow down to 20 to 25 patients for a half-day shift. Now my residents see a maximum of 12 patients per half-day, as dictated by the higher authorities based on ACGME-I guidelines. Then these same residents exit as specialists one day and suddenly they find themselves flooded with 30 patients in a half-day and they cannot increase their work output. They won’t know how to cope. And it will get worse when they get older and cannot work at the same pace as they were young. So what happens then? More will quit for the private sector”.

For the geniuses who rammed this residency system through a few years ago, there is metaphorical blood on their hands as our healthcare system gets more expensive and inefficient.

So going from the above, Singapore Medicine is going to get more and more expensive, even in the subsidized wards of our public hospitals.And the waiting times will remain long too. It is not just due to increased complexity of medical conditions in an ageing population or inflation. A big part of this is due to policies and systems that are inappropriate to our needs.

The next thrust about PGP and caring for the elderly is the emphasis on primary and community care.

The idea is eminently sound. Primary and community care are the places where most people should receive care. There is no need to choke up the acute general hospitals. But this Hobbit has observed several troubling trends in the last few years:

a)   There aren’t that many new GP clinics opening and these new “GP” clinics often offer aesthetic medicine as a major part of the services. In other words, the actual increase in capacity in the private GP sector offering “traditional” GP services may have been quite limited over the years, probably not keeping in line with the ageing population or the increase in population in Singapore.

b)   The A&E Departments of all restructured hospitals offer very good remuneration working as locum A&E MOs, with hourly rates of between $100 to 120/hour. Being an A&E MO is actually a safer bet than being a locum GP, because in the A&E there is always someone senior that you can get advice from on the spot. There is also a triage system that will assign the most difficult cases to the A&E specialists and residents. As a locum GP, you work alone and really, you try not to bug the GP who is on leave unless absolutely necessary.

c)   Career paths have also sprung up in restructured and community hospitals in the form of Family Medicine inpatient departments. This is not necessarily a bad thing, but it does take away a few GPs from the community.

So really, this Hobbit is really worried about who is going to do the heavy lifting in the GP and community care sector. Who is going to start GP clinics, run the FMCs and the polyclinics? That brings us to the rather touchy subject of foreign doctors.

We have relied and will continue to rely on foreign manpower to man our public healthcare services, doctors included. There is no escaping this fact. But there will come a time when a limit is reached. There will be serious issues when more than half of the profession consists of foreigners who are not locally trained. So one can safely say from a manpower planning perspective that for a sustainable environment, locally trained or Singaporean doctors must still make up the majority. Let’s put this at a reasonable figure of two-thirds. Guess what – if you look at the SMC Annual Report, we are there already for the public sector. In the latest available SMC Annual Report 2012, the public sector employed 6716 doctors. Of these, 2222 doctors were neither Singapore citizens (i.e. PRs or foreigners) nor locally trained. That comes up to 33.08%. The corresponding figure is far lower in the private sector. As the saying goes, Houston, we have a problem.

Given a choice, this Hobbit thinks our Pioneer Generation will prefer either Singaporean or foreign doctors who are locally trained. But as the numbers show, they have a one-third chance of not meeting one in the public sector. This figure is probably higher in certain departments and in the long-term care sector. Anecdotal evidence suggests that the public system has problems retaining even foreign doctors. Quite a few of them, especially specialists, actually leave for the private sector once they gain full registration with SMC. So will we have enough doctors, and by even a longer shot, enough local doctors to treat our Pioneer Generation?

All in all, the PGP is a great idea. But the PGP cannot be implemented outside the context of the other components of the healthcare milieu. And until we fix the other issues of our healthcare system, such as a climate that favours defensive medicine, staff retention, doctors’ training, etc, the PGP will face serious obstacles when it is implemented. $8,000,000,000 is a good start. But it won’t finish the job and it may not be enough.

For a start, we need to re-look at the whole system and ask –what are the policies and programmes trying to achieve in terms of the Golden Triangle of Affordability, Accessibility and Quality? It is said that no health system can achieve all three at the same time, maybe two at the best. One out of the three has to be sacrificed.

For the residency system – it is clear that quality is the main target. One may question if quality of training is actually raised by this system or if the system actually produces better specialists, but the intent is clear. By limiting residents’ workloads, mandating that core faculty trainers take off 40% of their time to supervise residents – they are trying to achieve quality. But this must be at the expense of affordability and accessibility since efficiency and hence productivity are severely curbed.

The Pioneer Generation Package is trying to achieve affordability, by declaring right upfront that our elderly do not have to worry about healthcare bills; hence the infusion of $8B over time. And since it is not means-tested, accessibility also improves. Hence by inference, quality is not a priority.

The various primary care and long-term community care programmes we have or that are being implemented is aimed primarily at improving accessibility. Affordability is a secondary objective since primary care is already quite affordable with the polyclinic system and the use of Medisave and CHAS etc. Quality takes a back seat especially in the long-term care sector.

The influx of foreign doctors in the public sector is obviously an attempt to improve accessibility.

Looking at the above, this Hobbit thinks the entire health system is being pulled in different directions by myriad policies and programmes; like torturing or killing a prisoner by quartering (Pulled apart by horses tied to the four limbs of the prisoner). That is why there is so much angst and frustration among public sector healthcare workers, doctors included,today. We need some clarity. Whatever the case, the status quo of this strategic ambiguity or strategic schizophrenia cannot go on. 20 years ago, the government was very clear – it was about achieving affordability – hence the title of the White Paper then “Affordable Healthcare”. What is it now? Is it still “Affordable Health Care”, or it now “Quality Health Care” or “Accessible Health Care”?

At the very least, we can choose two out of the three – such as “Affordable and Accessible Health Care” or “Accessible and Quality Health Care”. Please don’t kid ourselves that we can achieve all three –Affordability, Accessibility and Quality all at the same time. We need to prioritise and reflect this intent clearly across the board in a concerted way and not have programmes and policies that send out wrong signals and conflict with what is the overarching objective of our public healthcare system.

This latest budget for Ministry of Health has been announced and it is a whopping $7.1B. That is $7,100,000,000. And it is 22% more than last year. This is just great. MOH budget is growing faster than this Hobbit’s waistline, the COE and the price of beer at Kopitiam combined. It shows that the government is really serious about devoting more resources to healthcare.

At the same time, we should also ensure all this money is well-spent. So this Hobbit will now give some unsolicited and as usual useless advice to the bigwigs and bean counters in the Ministry of Finance on how to monitor and ensure how the $7.1B is spent. Given the limited intellect of this Hobbit (who had no A* in PSLE, did not score straight As at A levels, was never on the Dean’s list and most humbling of all, did not qualify to receive tuition from the most august Singaporean education institution of all: Learning Lab), this Hobbit actually doesn’t know what the money should be spent on. But this Hobbit does know what the money should NOT be spent on.

1          Another Cluster/Declustering/Reclustering Exercise

Speaking of clusters – please do not muck around with clustering, de-clustering and re-clustering exercises. It started in 2000 with the formation of Singhealth and NHG. Since then we had reclustering with NNI joining Singhealth and declustering of NUH and KTPH (Alexandra Health) from NHG and CGH from Singhealth. Many millions have been spent on these clustering exercises that to borrow a crude American term – it’s one big clusterfXXX.

According to the authoritative Wiktionary:

clusterfXXX (plural: clusterfXXXs)

1.    (slang, chiefly military, vulgar) A chaotic situation where everything seems to go wrong. It is often caused by incompetence, communication failure, or a complex environment.

Blame the dwarves for teaching this Hobbit such a vulgar word. But it’s really apt here.

2          Another Branding Exercise

Even if we do not spend money on clustering exercises, we must also avoid spending money on branding exercises. Branding exercises inevitably involve change of logos, letterheads, signages and uniforms and all these costs buckets of dough. It also creates a lot of confusion because just when you thought you figured out who is the staff nurse, nursing manager and health attendant, they change the uniforms again!

Having said that, this Hobbit is inclined to make one exception – Alexandra Health. Why is it called Alexandra when it is no longer in Alexandra but in Yishun and it is also set to sink its teeth and take a big bite out of Woodlands? To top it off, Alexandra Hospital is now managed by Jurong Health. This is even more confusing than figuring out the MCE.

3          Do not spend on yet ANOTHER trip to the Geisinger Health System if we are NOT prepared to accept the truth

We have sent many, many delegations to this fabled hospital/health system operator in the United States. This Hobbit has nothing against Geisinger. It’s probably a great place for doctors because it is physician-led (or that’s what the website says). But the most important lesson from Geisinger is one that we are unprepared to learn – which is it is a “closed-enrollment” system. You only get into a Geisinger facility if you  are already a member. That is why they can introduce all the right-siting and quality improvement programmes. The same applies to another system that was the flavor of the month about five to ten years ago – Kaiser Permanente. But obviously there is no such thing in Singapore – you can walk into a NHG Polyclinic in the morning, go to CGH SOC in afternoon and get seen at NUH A&E in the night. All in the name of patient choice.

Well, you can’t have it both ways, chum. So stop wasting money making long trips across half the world learning about closed enrollment systems when we do not have the political or administrative will to make our clusters closed enrollment systems. There are other easier ways to log frequent flyer miles.

4          A Proton Therapy Accelerator that costs US$100 million dollars

It was announced some time back that the public sector will have its proton therapy accelerator. It is rumoured that such a piece of machine will occupy a lot of space and cost something to the tune of US100M. Maybe things will get cheaper with time. But a course of treatment now in the USA on this machine is supposed to cost tens of thousands of dollars. Will we be much cheaper? Who is going to pay for it? Medishield Life? What is more,current evidence shows proton therapy outcomes are superior to other therapies only for paediatric, base of skull and maybe prostate tumours. Of course it is the prerogative of a private hospital if it wants to spend money on this. But to spend public money on such expensive and limited-use machinery is another thing altogether.  Maybe it’s just for Bragging rights (pun intended, for those of you who know what proton therapy is all about.)

5          A GP IT System that costs a bomb to develop and an arm and a leg to maintain

The much vaunted GP system that received funding from MOHH and developed by a local IT company a few years ago that was rolled out to certain GPs on a trial basis is going to bite the dust soon. Apparently, no one really wants to pay for the full upkeep of this system and the IT vendor has decided to pull the plug. Affected GPs have been informed already and the transition is going to be a painfully expensive one.

Actually, there are already two or three off-the-shelf GP IT systems that dominate the local market. There is no need to develop another one that costs a lot of money. Someone just has to eat humble pie and go to these dominant vendors and ask them to develop a common interface or platform so that the private GP clinics can operate or be linked together on a common platform. That’s it. Simple. No need for complex proprietary systems that have all the bells and whistles that no GP is going to pay for. They don’t need all this stuff. So, even as we bury this current GP system, please do not spend more money on another complex one. The old acronym KISS still applies – Keep it simple, stupid.

6          Pay American organisations (or any foreign body) to teach us how to train doctors and conduct exams which are not even recognised in the United States

Many years ago, our colonial masters allowed a medical school to be built in Singapore. But in order to maintain colonial supremacy over local medical graduates, the school was allowed to only confer LMS diplomas (Licentiate in Medicine and Surgery). The LMS graduates were not eligible to sit for membership exams in the UK (i.e. MRCOG, MRCP, FRCS etc) that were recognised as specialist qualifications. In other words, LMS was a dead end with no potential for one to be a specialist. And so many local graduates were repressed. They were often assigned to be Assistant Medical Officers to work for European doctors who in no way were clinically superior to them. One Malayan-born Tamil doctor Dr Chelvam with LMS actually managed to fool the examiners and sneaked in and passed the FRCS in 1929 and broke this glass ceiling.

Obviously no one learned from our bitter history and now we have surrendered our rights to conduct training and examinations to the ACGME-I system. So nowadays, even if our residents passed the exams in ACGME-I, (the suffix “I” meaning international), they are also not recognised for practice in USA where the ACGME system originated from.

So we have gone more than full-circle – we have actually deteriorated from our colonial days to something even worse – our LMS graduates in the past cannot take membership exams but now, our residents, after passing the ACGME-I (which is at least 80% similar to ACGME) exams, are not recognised for practice in USA.

So please, do not spend money on training systems and exams that are not even recognised by the countries from which they originated.  We are no longer under the colonial yoke.

7          Building under-sized hospitals

Many new hospitals are being built. After Sengkang, we may only need another two general hospitals. But maybe more are being built. Which is kind of scary. It takes a lot of time, money and people to start a general hospital.

It is probably better to have bigger but fewer general hospitals for quite a few reasons. Firstly, there is more flexibility. In the event that there is over-capacity in the system (if that ever happens), it is easier to close wards and clinics than to close entire hospitals. Secondly, you save on manpower costs because you don’t need separate departments of IT,finance, HR etc. Thirdly, you don’t need another set of CEO, CMB, CFO and another set of mission, vision and core values which seriously, no one remembers.  And most importantly, you also save on land because one big hospital takes up less land than 2 hospitals. The extra land can be used for park connectors and cycling tracks so that foreign-looking cyclists who don’t pay COE don’t have to rant at our motorists on our already congested roads.

Therefore, would it not have been better if KTPH had 1200 beds instead of having both KTPH (only 550 beds) and another hospital in Woodlands? We should learn from the mistake of building an under-sized general hospital as in the case of KTPH.

8          Do not spend on building someone’s legacy

Finally, humans are fallible, proud and mortal beings. Most of us want to be remembered well after we are gone. We want to leave behind legacies. Legacies can be free or frightfully expensive. People who control financial resources should guard against approving expenditure that may look reasonable and necessary but if you look closer, it is nothing more than something that materialised from the mind of a senior chap who wants to leave behind a legacy after his retirement. You may never prove with hard evidence that someone wants to leave a legacy behind. But like a pungent fart, you can smell it…..just look around us…..

There are white papers and then there are white papers. The recent Population White Paper will forever be unfortunately associated with the infamous figure of 6.9M. But not all white papers are as controversial as this one. Twenty years ago, the Government also published another White Paper. It was titled “Affordable Health Care” which served as a blueprint of sorts for Singapore for about ten years until a generation of folks running healthcare sort of ignored or forgot about this landmark WhitePaper and its recommendations.

This Hobbit thinks the Affordable Health Care White Paper was quite coherent and focused in its approach. Far more than what is happening in recent years, unfortunately.

So for those people out there who think that because a population upper limit of 6.9M was mentioned in the population White Paper, it will surely come to pass, fear not. The following will show that even if they are mentioned in a white paper, people can still forget about it or even do the exact opposite. This Hobbit gives a few such examples that were found in the Affordable Health Care White Paper which have not come to pass even now, twenty years later.

Philosophy

“Any health care policy has to trade off among four competing goals:

• Equitable access;
• Freedom of choice forpatients
• Affordability; and
• Freedom to organise production and to price

…”Given Singapore’s environment, we have to compromise the last goal: freedom to organise production and to price. (Page 13)

Except for the egregious example of the Susan Lim case, the private sector now has total freedom to price. In fact, freedom to price has been enshrined by the Competition Commission of Singapore when it outlawed the SMA’s Guidelines of Fees.

Basic Medical Services

“The Government has promised Singaporeans access to affordable basic medical services. This basic package will reflect good up-to-date medical practice, but it will not provide the latest and best of everything” (Page 17 to 18). “MOH will define the basic medical package which all Singaporeans will have access to, as it has always done”.(Page 21)

Actually, no one really knows what is the basic medical package (BMP), a construct as nebulous as the this year’s epic haze. We only know a few examples of what is NOT in the BMP.

The closest we have to a BMP is really what is claimable under Medisave and Medishield. But then again, there is a lot of funny stuff happening in Medisave too. For example, up till now, ultrasound-guided excision biopsy of breast lump, which is curative, is not claimable under Medisave, even though the scientific literature provides solid evidence supporting this therapeutic modality. People have been told to claim under (non-therapeutic) diagnostic breast lump biopsy. Either the folks in Medisave are living in the Stone Age or they do not know they are actually asking breast surgeons to deliberately code wrongly for what they are doing.

Private Sector Share of Hospital Sector

“The private sector presently provides 20% of acute hospital beds, mainly at the higher end of the hospital market. There is room to increase their share to 30% by 2010”. (Page 31) (According to Table on Page 37, this figure excludes A class beds in subvented hospitals and there will be a total of 9,690 beds in acute hospitals in 2010)

According to the Health Facts Singapore 2012 published by MOH, in 2010, there were a total of only 8064 acute hospitals beds, of which 6686 were to be found in the public sector and only 1,378 beds (17.1%) were to be found in the private sector.

There are another 2,195 beds in the public sector that were classified under “specialty centres” and not under “acute hospitals”.  Presumably this large number of “specialty centres” beds can be accounted for by IMH?

In other words, we are a long way off from the 9,690 acute hospitals beds that was forecasted in the 1993 White Paper, even if we take into account the opening of Jurong General Hospital in 2014.

Bed Class Distribution in Subvented Hospitals

“Fewer patients are choosing Class C, and more are opting for Class B2 or better. This trend will continue”; “Presently they (Class C beds) form 33% of beds in subvented hospitals. MOH expects this proportion to fall to 25% by the year 2000” (Page 36 and 37)

Again, this is way-off as experience tells us that there is great demand for Class C beds. SGH originally did not offer any C beds when the hospital was rebuilt in the seventies and eighties. That was described to be “a mistake” in 1989 and C class beds were built in a very limited way. Then in 2001, SGH had to offer C class beds in all disciplines.

We also know in other hospitals, waiting times for C Class beds are always the longest and the most frequently “up-lodged”. If you consider all the up-lodging that is happening everyday, then the actual demand and utilization of C Class beds could well still be around 33% today.

Private Wing?

“A subvented hospital may want to develop additional Class A wards or clinic suites, in order to offer new unsubsidized services. It may do this on its own, like any private hospital, provided the project is commercially viable and can be funded on a commercial basis without Government support. The project should preferably be run as a separate company with a different corporate name and image. Physically the additional facilities should be as distinct as possible from a subvented operation, e.g. in a separate bloc, which for practical reasons can adjoin the public hospital” (Pages 37 to 38)

This is an interesting one. If you read the words carefully,the term “private wing” is never mentioned. But the passage certainly describes a private wing in every sense of the word. However, no subvented hospital has a private wing today. Is it because there is no demand and there were no requests for a private wing to be built? Or is it because MOH has never approved the building of private wing? We may never find out….

Medical Research

“Improvements to the healthcare system do not depend on indigenous breakthroughs in medical research. While medical research increases the pool of human knowledge and can improve the quality of health care, it generally does not yield any financial returns, even over the long term”. (page 51)

This is a strong statement that bears reading over and over again. Yet, we are now building not one but two academic medical centre campuses (SGH/Outram and NUH/Kent Ridge) that will soak up billions of dollars of resources.

Medical Research

“The third category of research should be undertaken only with strong justifications. Even then we must be careful to avoid raising unrealistic public expectations that the new procedures and drugs will become universally available, and will successfully treat conditions which were previously untreatable”

Third Category:

“Research that has practical applications which are expensive, e.g. organ or bone marrow transplantation. Such work is often developmental, involving experimenting with new procedures or drugs that have been developed elsewhere. It can thus raise health care costs without commensurate returns. (Page 52)

Again, this has been turned on its head. One just needs to read the papers and find reports of groundbreaking research on rare diseases,expensive drugs, robotic surgery etc. One may argue whether such research is good or undesirable but this Hobbit thinks no one can deny that the frequent reports of such work have certainly raised unrealistic public expectations about what treatment modalities can become universally desirable.

Postgraduate Medical Training

“MOH is responsible for coordinating postgraduate and advanced medical training at subvented hospitals. Because of the expense involved, and the need to deploy talent optimally, the training of specialists should be based on service needs. It must be centrally coordinated and periodically reviewed”.

This example is one of a flip-flop in thinking. Long ago, everything was centrally controlled. Then, everything was decentralized. First, restructured hospitals can recruits as many trainees as they could, to the point that trainees who have passed their postgraduate degrees like MRCS cannot find advanced specialty trainee or registrar jobs. With the introduction of the ACGME-I system, residency decisions were passed to the residency advisory committees (RACs) sponsoring institutions, program directors etc. Well, these guys took their jobs seriously and decided to promote some residents they thought were good to senior residents. Then in one fell swoop,some wise guy decides to unilaterally overturn this and override the governance structure that had been set in place, even reverse some promotions (promotion letters already sent out) of some residents.

So it has been centrally coordinated, then divested to the sponsoring institutions and RACs, and then now abruptly centralised again.Couldn’t everyone have been spared all this anguish and angst by just sticking to the doctrine of centralisation in the first place?

Should we have another White Paper on healthcare?

Lately, white papers may have gotten a tarnished name. But lest anyone misunderstands, this Hobbit thinks that having a healthcare white paper once in a while is a good thing. The above examples are just a few examples of what did not happen. Some recommendations were quite off the mark, but many did not happen not because these original recommendations were wrong, but probably because conditions have changed or some folks have decided to ignore the prudence that the White Paper was trying to inculcate. And to be clear, many good things did come out of the 1993 White Paper.

A White Paper forces policymakers to think long term and commits them publicly to a course of action that has been carefully thought through previously. Such commitment requires gumption, clarity of thought and allocation of resources. Not everyone may agree with what is written in a White Paper, but it also puts everyone on the same page. There is no ambivalence and vacillation in a well thought-out White Paper. That sure beats making plans in secret with minimal consultation, making things up as you go along or unleashing nasty surprises on stakeholders. The residency is one such bad example. There was no light on how the decision of using the ACGME-I residency framework was arrived at; in retrospect, clearly no in-depth understanding of the resources that were required to operate the ACGME-I framework; and no roadmap for career progression of residents (hence the sudden decree to overturn certain promotions). And hence, it is now still mired in darkness and people down in the trenches have to try to make the system work by instituting ‘patches’ haphazardly like engineers and technicians trying to fix some nightmare software programme. And this Hobbit reckons we will still be mucking around for a long time to come.

We actually need another white paper on healthcare. The last one in 1993 was a good piece of work. We can have another one that is just as good, if not better.

Before we know it, November has come and 2012 is drawing to a close. 2012 had its usual own share of the inexplicable and the unanswered. But this hobbit thinks it’s time to be positive and believe 2013 will be better than 2012. Perhaps in 2013, we will know understand why 2012 went the way it did, especially with regard to what’s happened to SMC. Maybe someone would produce a TV series similar “X-files” in the future and answer some of these questions. But for now, let’s keep these 10 questions unanswered for 2012:

Question 1 Did MOH investigate other such cases? If it did, why did it only refer these two cases to SMC?

The recent SMC press release implied that that SMC only decided on the 2 aesthetic cases (the cases involving Dr Low Chai Ling and Dr Georgia Lee) because these two cases were initiated under the old law whereby SMC could only investigate cases where there had been complaints by other parties. It could not investigate other cases if there were no complaints. However, with the new law, SMC could initiate investigations even when there are no complaints. This is true. However, the abovementioned 2 cases were complaints initiated by MOH. So the unanswered question is – are these two cases the only ones brought by MOH to SMC? And if so, why did MOH only bring two cases to SMC and not others?

Question 2 What is the definition of “legally embarrassing” work? 

Only when we know what clearly constitutes an embarrassment, can we then try our level best to prevent this from happening again.

Question 3 Should SMC pay for the regulatory work of its most frequent user, the rather “better” funded Ministry of Health? 

The SMC is supposed to be self-funded by doctors’ subscriptions. Yet the largest user of SMC is the MOH. Can we actually know the cases that were referred by MOH constitute what percentage of the total caseload handled by SMC? And if MOH is the “chief complainant” and not aggrieved individual patients, should not MOH share in the cost of running SMC? Why should doctors fund MOH’s regulatory actions? MOH has a budget of billions, SMC only a few millions. By the way, this hobbit knows of no other country in the Anglophone or developed world where the most frequent user of a medical council are the authorities themselves. This hobbit would be happy to know if there are other similar countries.

Question 4 Can someone please explain why there are two Executive Secretaries instead of one?

The Medical Registration Act (Section 10) clearly states the SMC may appoint  “an executive secretary”. Now there are two. Have things improved after there were two executive secretaries?

Question 5 What is the main mission of SMC’s lawyers? 

What is the main mission of SMC’s lawyers? Is it to secure justice or to secure a conviction? Is payment in-line with the mission? A senior lawyer highlighted the main difference between a DPP and a lawyer at a SMA talk held recently. He said a DPP’s main mission is to ensure justice, not to secure a conviction. A lawyer’s main intention is to win the case for his client.

Question 6 Can SMC use government legal officers instead of private sector lawyers?

In the case of the Medical Council of Hong Kong, a Government Counsel of the Department of Justice is responsible for presenting evidence to substantiate charges in the prosecution process. Can we do likewise, use an officer from the government legal service? Why does SMC use lawyers from law firms instead? Are there very compelling reasons to continue this practice?

Question 7 Why were there 10,000 votes for no one?

In the recent SMC elections, about 14,000 votes were cast in total for the five candidates that stood for election. There are about 8000 SMC fully-registered doctors who had 3 votes each. In other words, a grand total of some 24,000 votes could have been cast on human candidates, but only 14,000 were so. That means doctors who could vote chose to cast 10,000 votes (41% of all votes) for “00” i.e. “nobody”. That’s 10,000 votes worth of food for thought. All of the candidates had very good if not sterling CVs. And yet, the most popular “candidate” by far was “00”. If we don’t call this a crisis, this hobbit doesn’t know what is. It may not be long before the figure of 41% goes beyond 50%. (No doubt, instead of genuine reform to ensure credibility and competence, some twit will now contemplate removing the option of “00” to prevent further embarrassment). And by the way, there is no ‘collective action’ here, as some people are wont to say. 8,000 doctors cast 10,000 votes on nobody without any coordination by anyone.

Question 8 Why are there so many SMC members from the local medical schools?

The composition of the SMC can go up to a maximum of 25 members: -12 elected members and 13 appointed ones. Of the 13 appointed ones, one of them is the DMS and another four members are nominated by the two local medical schools (i.e. four ‘allocated’ seats, two from each medical school). There are currently only 24 members because one seat reserved for Duke-NUS GMS is vacant. That leaves SMC with another eight appointed members. As if though the medical schools are not already sufficiently represented by the four allocated seats, of these remaining eight, three appointed members are again from the local medical school. Why is there this phenomenon whereby so many appointed members are staff of the local medical schools (Excluding the DMS, there are still 7 out of 24, assuming Duke-NUS GMS fills its 2nd seat soon – as it should)?

Question 9 Why so few GPs on the SMC?

Contrast this to the sad situation of GP representation on the SMC. There must be about 2000 GPs in Singapore. Yet there are only 2 GPs on the SMC, and both are elected members. It is true that some things are beyond anyone’s control, which includes getting GPs to run for SMC, let alone getting them elected. But surely of the eight appointed members that need not come from the local medical schools, at least one or two can be GPs?

Question 10 Why are SMC members (unpaid) volunteers?

It’s 2012 going on to 2013. Nothing much is free anymore, other than parking at the government mortuaries and columbariums. So the recent SMC press release about SMC disciplinary committee members being volunteers probably cuts no ice with either the public or doctors. Being unpaid is no excuse for doing something that is legally embarrassing, especially when the lawyers representing all parties at SMC hearings are still being paid and the job of SMC is so important. So maybe we should start paying our SMC members a decent honorarium for their work. If reservists can get reimbursed their civilian salaries, why not our SMC members as well? SMC can probably still balance the books, if it used legal officers instead of lawyers and cases referred to SMC by MOH are funded by MOH instead of SMC. The SMC needs to get the job done, and if it needs “reimbursed” volunteerism, so be it.

p.s. There will probably be no long posting in December. This hobbit is also going on an unexpected journey 😉

It’s been some two months since this Hobbit posted anything on Facebook . I apologise for this lack of productivity as I have been recovering from the twin shocks of watching HDB clinic rental bids reach $32,800 and the Incredible Hulk in 3D these last couple of weeks. Seriously, the Hulk looked puny next to the rent.

Recently there has been some disquiet and murmurings about the community pharmacy initiative by MOH which is also closely associated with another MOH initiative – Community Health Assistance Scheme (CHAS).

First, let the Hobbit clarify what is CHAS all about – CHAS is nothing more but a new and lousy name for the old PCPS scheme, but now extended to more people, namely the not so old and the not so poor. So essentially, it’s a better thing with a lousier acronym. It helps more people and gives us GPs more business. Except that the paperwork is really quite tedious. It involves the CHAS applicant and all his household members declaring their incomes. So the best way to get your parents to qualify for CHAS, even if you earn a million bucks, is to kick them out of your house and into a small HDB flat where there earnings per capita for that household is one big kosong.

Next thing you should know about CHAS as a participating GP is that there are like all helpful government initiative – auditors. You should know by now that civil servants are not rewarded for solving problems but for preventing abuse and protecting the gluteus – hence the need for auditors. I know of a case of a GP being told by the auditors that she was overcharging. The total bill (consultation and medicine) was a whopping $28 (Singapore dollars). In any case, I don’t think this was the “lady doctor” Mr Lee Kuan Yew was referring to over the recent SMA Annual Dinner.

Next is this issue of Community Pharmacy. Now this is a more touchy subject mainly because it involves Big Pharma (not to be confused with Big Mama, which is a movie about how voluptuous and nubile female drug reps become big mamas when they get married, then have 3 kids, gain 20kg and fret over PSLE after they leave Big Pharma).

But back to Community Pharmacy. Many GPs who attended the recent behind-closed-doors, off-the-record and under-the-radar but definitely beneath eerily still waters sharing session held somewhere near Outram MRT station asked how come the GPs do not have access to the low-price drugs that can be available to Community Pharmacies?

The answer is simple and it is not because someone realized more doctors attended opposition rallies than pharmacists. It is Big Pharma. These drugs are sold by Big Pharma to public healthcare clusters at low prices based on the agreement that they cannot be resold to other healthcare providers without Big Pharma’s agreement. If the whole of Singapore lived on drugs at these low prices, Big Pharma’s profits would suffer. And you know that the likelihood of that happening is slightly less than the MRT not breaking down, taxis picking you up at 11:45pm and COE going back to 20K a pop again.

Let this hobbit put it another way – we have had aggregate buying by the public hospitals for many years now (~10 years?). If the public hospitals could have shared their low prices with GPs, they would have done so long ago. They haven’t, because obviously they probably cannot.

The CHAS patients who presumably have access to these cheaper drugs at Community Pharmacies will be means-tested ones and hence a case can probably be made to Big Pharma that they should make available to these poor patients their drugs at these reduced prices. These poor people probably never could have afforded them anyway and this translates into new business and market share for Big Pharma.

In the meantime, “richer” non-CHAS patients will continue have to bear higher prices, hence in a way subsidizing these poorer patients and helping to maintain or grow Big Pharma’s profits.

Is this fair? Well, life isn’t fair, so let’s get used to it. Because there is no serious and practicable alternative – Big Pharma has tremendous power. They invest in Singapore and provide employment. They have the capability to practice territorial pricing, which is why our drugs cost a lot more than in JB. And more importantly, they have the power to stop doing business in Singapore, because Singapore, for all the huffing and puffing, is a small market that Big Pharma can bypass and ignore either in sales or investment. It will be similar to medical device importers telling Singapore they can easily forget about the little red dot if the regulatory costs become suffocating. You, the humble GP, cannot bypass Singapore or create a lot of investment and employment.

All this sounds terribly depressing. Well, it is. And it isn’t. Because CHAS still presents opportunities. Let’s look at a few:

• Subsidies and low pricing aside, a system of separating prescribing and dispensing is intrinsically more expensive and inefficient than a GP clinic doing both. Think of the additional costs involved – rental, manpower etc. The GP clinic is still the most nimble healthcare construct around. Life gets tougher, we evolve. Like cockroaches and algae, we can survive nuclear attacks.
• CHAS will bring more patients (barring the byzantine admin procedures). Personally, I think even with community pharmacies, chronic patients who need more than 4 drugs will still stay in polyclinics and subsidized SOCs. Those with less can move to CHAS, provided they only need one expensive drug, or maybe two at most.
• You can choose the with-drug or without-drug package. Chances are, most GPs will use more generics and choose the with-drug package for the CHAS patients. And there are more and more good generics out there.
• It’s an opportunity to raise our consultation fees to reflect true costs. If CHAS can offer a consultation rate of say $35 or $40 without medicines, then it will be obvious managed care companies that continue to offer rates of $10 or less are idiots that deserve to be ignored if not boycotted. You don’t need a guideline of fees to tell you that.

The last point on consultation fees deserves elaboration. What is the true fixed cost of a GP’s practice? That varies because of rent, working hours and pay expectations. Someone said that you need about $200 an hour to survive. This is not far off. If we closed our dispensaries and only earned from consultation and procedures, and expect an annual gross income of 200K a year (including employer CPF, leave etc); hire two clinic assistants (you probably only need two if you didn’t dispense) and paid a rent of say $6,000 to $10,000 a month, we still would need to reach a turnover of about $30,000 to $40,000 a month. If we worked an average of 48 hours a week, we would need to generate revenue of about $150 to $250 an hour for every hour the clinic open. Assuming you can see 4 to 5 patients an hour, you need consultation charges that range from $30 to $50. But most of us never do – because we subsume these costs under the drug mark-up. And that is also why many GPs are turning to aesthetics – because it is a lot easier to break this $150 to 250 an hour threshold with aesthetics than the grind of traditional GP work.

So, I guess GPs don’t really have to fret about Community Pharmacies or CHAS too much. The real danger is not to the GPs but policy failure. The whole point of Community Pharmacies and CHAS is to decant patients from the polyclinics and SOCs. But means testing hasn’t arrived in SOCs and polyclinics yet and these facilities are being built and equipped to ever-higher specifications. They represent terrific value. If I were a subsidized patient in the SOC or polyclinics and have all the time in the world to wait, why would I ever go to the GP? As such, CHAS may only appeal to existing GP patients who can decrease their out-of-pocket payments with CHAS or to newly-diagnosed chronic patients who have never tasted the forbidden fruit of fancy and cheap polyclinics and SOCs. In other words, no big shift or decanting will occur from the public sector to the private.

Long, long ago, in a galaxy far, far away (actually to be exact – In January 2005), when the current DMS had just been DMS for a couple of months, Ms Salma Khalik of the Straits Times wrote that MOH will stop doctors from dispensing after interviewing the DMS. This caused quite a furor then in the medical fraternity then and the Ministry of Health then wrote to the ST Forum to clarify and the DMS also wrote to SMA to explain. This hobbit also wrote about this incident in stout defense of this DMS. (please seehttp://www.sma.org.sg/sma_news/3701/hobbit.pdf ). The MOH minutes were actually released to SMA and it was reported then that “Of the separation of drug dispensing and the practitioner as in developed countries, DMS said it would not happen soon in Singapore. It would take some time before doctors in Singapore appreciate the benefits that such a system would bring to their practice.”

It’s been seven long years and many stranger things have happened, like outlawing the Guideline of Fees, allowing lawyers and judges to sit on SMC disciplinary tribunals and this confection called (American-ised) residency. Hence, the real but unspoken concern on the ground is, will this initiative lead to something more ominous down the road, the proverbial beginning of a long and slippery slope? DMS said it would not happen soon in Singapore. But that was said in 2005 and it’s now 2012. So perhaps it is time the medical profession gets the reassurance from DMS again that Community Pharmacy is not a prelude to the separation of dispensing and prescription.

Call this hobbit insecure, wary or even paranoid. But as bitterly painful events in the last few years have shown, trust is a commodity doctors can ill-afford nowadays under the current climate.

Back to CHAS. Will CHAS work? Against the backdrop of accountability, prevention of abuse and transparency that policy makers and bureaucrats are trying to paint, patient and GPs must also see the value of CHAS against the costs of CHAS. The costs of administration of CHAS, including processing of claims, using the proprietary IT system etc, must be accounted for. The costs of the patient making a trip to the community pharmacy must also be considered. And since time is money, costs also include time spent.

Meanwhile, GPs take heart. Cockroaches and algae can survive nuclear attacks….