Could We Or Covids Have Done Better

The Covid-19 White Paper was released on 8 March 23. This hobbit thinks this was a very commendable effort to look back at what happened that was led by a former Head of Civil Service that is known for his frankness and clarity of thought.

It correctly identified the two major shortcomings made by the government – the U-turn in mask policy and the blow-up in cases that happened in foreign worker dormitories. And this in itself, is a win for transparency and humility. Two very rare commodities in the world nowadays. It is also noteworthy that the two errors arose from essentially the heuristic error of anchoring. Just because the coronavirus in SARS was infectious only when the patient had fever doesn’t mean that another coronavirus will behave likewise. We were anchoring on our past experience with the SARS virus and hoping the Covid-19 virus will behave likewise.

But enough big talk. Now for the small talk that regular readers of this column seem to enjoy much. There are some episodes during the pandemic that are worth remembering but not mentioned in the White paper, just for laughs, if nothing more. These include:

The Virus Vanguard. These are official superheroes no less, since they first appeared in government Facebook webpages, albeit for about only a day in April 2020. We remember our disappeared champions – Circuit Breaker, Care Leh-Dee, Dr Disinfector, Fake News Buster and the (drumroll please) MAWA Man (Must always walk alone, the very antithesis of Liverpool fans). This hobbit hopes that they have NS liabilities, so that in the next pandemic or epidemic we can serve the SAF100 on them to return.

Pivot to F&B Sector. The KTV cluster in 2021 was a result of several KTVs that have “pivoted” to the F&B sector (with assistance and sometimes even grants from the relevant  authorities). A good and well-meaning idea in itself except that these newly pivoted F&B outlets did not have any commercial kitchens. So obviously they had to cook up something else on these premises which resulted in the cluster.

Strangers Sharing Same Hotel Room during Quarantine. At the start of the Omicron wave around December 2021, some folks were made to quarantine in the same hotel room with complete strangers. Naturally, this nutty idea was quickly panned by many. Between a full-height walled cubicle in Singapore Expo and sleeping with a stranger in the same hotel room for about 7 to 10 days, most folks will prefer the former. C’mon, even in an SAF exercise, I have my personal basha tent. This hobbit thinks the guy who came up with this probably liked Frank Sinatra’s “Strangers in the Night” a little too much.

CB and Tightened CB. Kudos to the wordsmiths who were always on top of the word game during the pandemic. These include calling a lockdown a circuit breaker or CB in short. This evolved to a Tightened CB later on. And at about the same time, the government was putting out Chinese-dialect short videos to get the message out to the elderly in the Chinese community. Whoever came up with the tightened CB bit should also be sent for some dialect classes.

Die Another Day. This incident arose also in late 2021 when a MOH Director said mortuary directors could handle dead bodies when the cause of death was Covid-19. This was refuted by the Secretary of the Association of Funeral Directors’ Singapore the next day in The Straits Times Forum which stated clearly that MOH guidelines prohibited them from handling such bodies outside of hospitals. This is clearly NOT a case of Everything Everywhere All At Once as the left hand didn’t know what was happening with the right hand. It is also nice to know the Association was given a President’s Certificate of Commendation for exceptional effort and significant contribution to fighting Covid-19. Incidentally, organisations such as SMA, CFPS, AMS, SNA, SDA and PSS weren’t. Obviously someone either forgot about or doesn’t like these guys?

Let us now get down to the White Paper proper and move back into the serious stuff. What really hit home for this hobbit. The White Paper really had their finger on the pulse when it stated on Page 67:

“However, some of the (i.e. SMM) measures were overly elaborate, difficult to operationalise and explain, and therefore confused the public. Re-opening the economy in phases while limiting the spread of community infections turned out to be a more complicated, and emotionally affecting, journey than expected. All this highlights the need for us to exercise greater flexibility in a crisis, go for broader brush but more implementable measures, and to guard against the instinct to aim for unrealistic standards of perfection”.

On Page 74, the White Paper essentially put out the same message again:

“With future pandemics, we will also need to exercise more flexibility. During COVID-19, at times we allowed the perfect to be the enemy of the good, for example the over-calibration of some SMMs and treatment protocols. In striking the right balance between achieving precision and ease of implementation in our public health protocols, we should guard against leaning too much in the direction of the former”.

Very important points that were most eloquently articulated. Beyond these wise words, this hobbit would like to draw attention to this graphic that was put out in late 2021 by Lianhe Zaobao which told vividly how wrong can matters get:

Like what this hobbit has said before, you don’t have to know Chinese to appreciate the ludicrous complexity the “system” had become before thankfully someone decided to implement Protocols 1, 2 and 3.

It is perhaps importantly to go one-step further to discuss why the “system” went off the cliff in terms of complexity and impossibility (rather than ease) of implementation, especially in the area of public health and healthcare.

First, let us remember, whether we like it or not, that protocols, circulars, instructions, directives etc, are written and put in place by people (i.e. real humans, not halflings, elves and orcs). And what drove these people to do what they did? This hobbit can proffer several possibilities:

  • The people who wrote these protocols really have no real on-the-ground experience running healthcare facilities such as hospitals, nursing homes or clinics. They probably grew up in a nice white building; from sitting behind a desk to sitting in a cubicle, before finally being holed up in an office and adorned with a personal assistant to show they have arrived. Hence, just armed with a little theoretical knowledge and no frontline experience, they write protocols the way novelists write fantasy stories.
  • These people are more afraid of losing their jobs more than solving real-life problems, and think that the best way to keep their jobs is to cover their backsides and to write protocols and directives that cover every possibility and exception without thinking how the people on the ground will cope. Never mind you cannot possibly comply with what they wrote. That’s your problem, not these people’s.
  • They are just plain stupid (which is unlikely, since they can write such complicated protocols. Maybe they have spectrum disorder, but they are probably high-functioning ones rather than stupid).
  • Various combinations and permutations arising from the above three possibilities.

There are of course other possibilities, but it would be impossible to explore all of them in the interests of time and readers’ attention. Of course, this hobbit is NOT about to excoriate old wounds, start a new round of fault-finding or try to settle old accounts. But it is important to state that these people have written and issued protocols and directives that have caused untold grief and profound degradation of morale among front-line healthcare workers during the pandemic. This hobbit thinks the morale hasn’t quite recovered fully even now. Quite a few people are still scarred and angry.

So, in the name of all that is good and true, this hobbit beseeches those that are in the high places of power that they do not assign very important tasks such as writing of protocols and directives to these same dangerous people again. Put them somewhere else where they can still earn a living off taxpayers’ money but do less harm, like dress them up as MAWA Man, Care-leh-dee and Dr Disinfector etc and send them to Cosplay conventions. Better still, we can put them onto a Chingay Parade float that has a big overhead banner which has the words “CBs”.

Monkey See, Monkey Do?

It’s December and the season to wind down. But sometimes, they just won’t let you. You sense a grave disturbance in the Force. The Dark Side is lurking just down the corridors of power, and you hear it’s mocking snigger giving way slowly to cackling, evil laughter. Ready ever to exsanguinate and impose great pain on you.

We are of course talking about the Blood Suckers Group (BSG) (oops, I mean Blood Services Group) of the Highly Soporific Authority (HSA) (oops, I mean Health Science Authority) and its latest circular to all Hospital Transfusion Committee Chairs and Hospital Laboratory Managers titled “The Need for 2 Separately Drawn Samples for Pre-transfusion Testing w.e.f. 1 Jan 2020″.

The BSG has just decreed that for all new patients (without prior records of blood grouping) for what we mortals know as Group and Cross Match or (GXM) will now need to submit TWO separately drawn blood samples taken on SEPARATE occasions which are preferably drawn by TWO persons.

This is to “detect and prevent ‘Wrong Blood in Tube’ (WBIT) errors”.

This Hobbit is given to understand that this requirement does not apply to restructured hospitals because they have already implemented “an electronic patient identification system” that is used “verification of blood samples meant for pre-transfusion testing”. Again, in plain mortal-speak, it means restructured hospitals have IT systems that can print patient stickers with patient-specific bar-codes.

For a start, these geniuses can improve their communication skills by taking lessons from Chewbacca.

But apparently, no private hospital in the Middle-earth have these fantastic sticker-printers that can print bar codes. So now, whenever a patient in private hospital needs blood, he has to be poked twice by two different people.

When one changes policy or implements a policy, there are trade-offs in costs and benefits which must be looked into and in this day and age, and explained to the affected parties (because in this day and age, affected parties are not morons).

  • For example, how many WBIT incidents and near misses have there been in the last five years? What is the average number of incidents per year?
  • How many GXM requests are there in a year from private hospitals? What is the additional cost of doubling this number of blood group testing?

Internally, one has to also conduct a cost-benefit analysis of this proposed new policy of poking everyone twice.

  • Give an imputed value to the value of a life saved (health economists can do that) by taking blood twice from each person.
  • Give an imputed value to the pain suffered for the additional blood sample taken
  • Give an imputed value to the possible complications (e.g. hematoma, infection etc) of venipuncture (low risk is NOT no risk).
  • Work out the manpower and material cost (reagents, supplies, biohazard waste disposal etc) of this additional testing requirement

Then deduct the costs from the proposed benefit and ask -does this still make any sense or cents?

While patient safety is a laudable aim in healthcare policy-making, there is cost to additional patient safety once we have achieved an acceptably high level of patient safety. It is naïve to think that patient safety has to be pursued at all costs (no matter how catchy that sounds) because there is a limit to resources. If we have unlimited resources, we can pursue something at all costs. But alas, the inconvenient truth is we don’t have unlimited resources and the healthcare budget is the fastest growing budget in government in the last 10 years and healthcare expenditure likewise is growing rapidly.

There are examples in the crime fighting world as well as the IT world where real people deal with stuff like limited resources. Law enforcers will tell you privately it is always impossible to eradicate ALL crime in society and some low level “ambient” level of crime is quietly allowed to exist. Of course, the police will usually and vigorously pursue all violent or serious crime, such as murder, robbery, kidnapping etc. Petty crimes such as pickpocketing, illegal money lending and debt collection, littering, speeding etc, they all exist to varying extents in societies and are seldom completely eradicated. This is because the cost of bringing all criminals and lawbreakers to justice is usually too high, not just in dollars and cents, but also from the perspective of the general population’s loss of peace and privacy.

In the IT world, when we buy or deploy a new IT system, let’s say a hospital IT system – If we specify that the IT system’s availability is rated at 99% (i.e. downtime of 1%), it may cost, say, $10 million dollars. But if you want the same system to have an availability of 99.9%, the price may go up to $12 to 13 million. You are paying an extra 20 to 30% for just an increase of 0.9% in availability from 99%. This also demonstrates the principle of diminishing return.

This hobbit suspects (100% speculation) that we are going to incur a lot of costs and inflict a lot of physical pain just because some genius decided that WBIT incidents should be eradicated. The problem is, one is not even sure poking a patient twice (especially by the same person, which is permitted but not encouraged) is even effective in eradicating all WBIT errors. But this hobbit also suspects, in the mythical realm of Middle-earth that bureaucrats live in and when “patient safety” is mentioned, the consideration of limited resources does not exist at all. But the hard truth is, outside of Middle-earth, even for a sacrosanct issue like patient safety, limited resources in terms of money, people and time are very real considerations. This hobbit further suspects that because the public hospitals are not affected because they can print the fancy patient stickers, private sector concerns were not addressed before this new policy was declared.

On 4 Dec 2019, a major private hospital group issued its own circular to all doctors practicing in its hospitals stating that the requirement to take two specimens of blood stemmed from the fact that HSA’s BSG was accredited to this organisation called AABB (American Association of Blood Banks) and that AABB required its members to follow this practice so as to remain accredited with it.

This makes the waters even murkier and begs even more questions. Last I heard, Singapore is a sovereign state and we do many things differently, like driving on different sides of the road. We also spell “organisation” with an “s”, not a “z”. The last time we tried doing things the American Way in healthcare, like Residency, it didn’t turn out well. So, if it is indeed an AABB requirement, then Singapore healthcare stakeholders must ask – what are the benefits of being accredited to AABB? Versus the costs? Not just benefits to HSA BSG, but to ALL Singaporeans and Singapore. Is our situation similar to AABB? Maybe there are many WBIT incidents in USA. What is the number of incidents per, say, 1000 GXMs? I.e. the rate of WBIT in Singapore vis a vis USA and other first world countries?

So many questions, so few answers. If the private hospital circular is factually correct and the private sector is doubling the number of blood specimens taken for GXM just to satisfy some bureaucrat’s desire to fulfill some obscure American accreditation requirement, then it is yet another case of monkey see, monkey do.

Actually wait, this hobbit stands corrected. Monkeys are actually quite intelligent.



Back to 1993: Health Care Philosophy

The business of running a health insurance is based on actuarial science. Health insurance is not rocket science. However, embedded in the actuarial projections of health insurance is a lot of data that can be explained by the discipline of behaviorial science.

The recent policy announcement by the Ministry of Health to mandate that new policies underwritten as Integrated Shield Plans (IPs) offerings will no longer have “first-dollar coverage” has engendered much discussion and discomfiture among certain stakeholders, noticeably among policy holders and healthcare providers. The common term for first-dollar coverage is “riders”. Apparently, 1.1M people in Singapore have bought these riders whereby they do not need to make any out-of-pocket payments either as deductibles or co-payments when they make insurance claims. To complicate things, many of these IPs are also “as-charged” policies whereby the insurance companies pay out whatever the healthcare providers have charged. And to add salt into the wound, the SMA Guidelines of Fees had to be withdrawn in 2007 because it was deemed to be anti-competitive.

Expectedly, it was found that claims for these plans rose far faster both in size and frequency than those that did not have riders, suggesting that there is overcharging and over-servicing for these plans, leading to over- and unnecessary consumption of healthcare. Doctors in Singapore have been blamed by some quarters for this phenomenon.

Many countries, such as USA, Australia, Canada etc have had much more experience in health insurance than Singapore. And the experience is consistent and unequivocal – first dollar coverage and as-charged plans always lead to much higher and more frequent claims than those that do not have these characteristics. Human behavior and self-interests dictate that the parties involved (patients, doctors and hospital administrators) will work to create these unfavourable and unsustainable outcomes.

Why were insurance companies allowed to offer IP health insurance products that offer first-dollar coverage and reimbursement at as-charged rates when experience world-wide has shown that such products will lead to runaway healthcare inflation? This is perhaps not the forum to examine this in detail but those who are in positions of power should perhaps quietly and introspectively ponder this.

Singapore, because of the safety nets of a well-funded and equipped public healthcare system and Medisave and Medishield, actually came rather late into the game of private medical insurance. If so, Singapore should and could have easily learnt from others and avoid making the same mistakes. But alas, we did not. For whatever reasons, whether by purposeful policy design or mis-design, or inadvertent regulatory neglect, first dollar coverage riders and as-charged plans made their way into our healthcare financing environment in a big way, leading to the problems we now see.

And if indeed Singapore doctors did contribute to bigger and more frequent claims of IPs that are as-charged and with riders, it was hardly surprising. Singapore doctors are humans after all. Are they expected to behave very differently from their counterparts in other countries in the developed world?

A senior health correspondent argued recently that if all doctors had worked ethically and charged reasonably, the problem would not have arisen in the first place. There are black sheep in every profession, not just the medical profession. Stating the obvious (that there are black sheep) while alluding to an ideal impossibility (that ALL doctors work ethically and charge ethically) is neither helpful nor responsible. It merely polarises the discourse unnecessarily and expediently villainises a certain segment.

We can think of other similarly unhelpful statements like “If all e-scooter riders rode responsibly, there would be no need to register e-scooters” or “If all vehicle drivers drove according to traffic rules all the time, there would be no accidents, no need for the traffic police and no need even to purchase motor insurance”.

These are obvious truths, but unhelpful statements if we are to arrive at practical solutions that is sustainable for all stakeholders. In this vein, former Health Senior Minister of State  Chee Hong Tat recently provided a useful framework by his use of the terms over-consumption, over-charging and over-servicing.

Over-charging is a price issue while over-servicing pertains to the volume and scope of services rendered. Over-charging and over-servicing independently or together can lead to over-consumption.

MOH has obviously thought through some of these issues and have started initiatives that are aimed at tackling the problems.

The first and most important of these is the formation of the MOH Fee Benchmarking Advisory Committee. Fee guidelines or benchmarks is a good tool to guard against overcharging and underservicing. If the benchmarks are well constructed, this hobbit  believes the vast majority of doctors will charge within the benchmarks. This is because for the vast majority, to justify why one has not charged within the benchmarks is just too much work and carries too much ethical risk.

On the other hand, benchmarks can also be a guard against underservicing. Some third party administrators have fees scales that are so unrealistically low that providers refuse to offer services that are required. Fee scales that fall below that of the official benchmarks will become questionable in that are these companies truly interested in provide adequate care at reasonable prices or are they just interested in slashing costs and making a profit?

As long as doctors charge within the benchmarks, insurance companies that have panels of preferred doctors may and should become unnecessary.

The annual minimum co-payment cap of $3000 that has been mooted that only applies to panel doctors should also be unnecessary as such. The $3000 cap (with no lifting of cap) should apply to all providers as long as these providers undertake to charge within the benchmarks.

Insurance companies may then also offer fee scales that correlate to the lower end of the benchmarks, but these must lead to lower premiums and savings for patients, so that patients know they are getting bargain insurance products versus premium products that enable them to access any healthcare provider as long as the provider charges within the benchmarks.

Over-servicing is a more difficult issue to tackle because subtle over-servicing is often hard to differentiate from professional judgment that errs on the side of caution. Gross over-servicing is easier to detect and can be discovered often through audits and utilisation reviews.

However, it is important to differentiate insurance fraud from over-servicing and not conflate the two. The case of a hernia repair bill that cost >$30,000 which included a tummy tuck, breast augmentation etc., should be investigated for fraud, especially if the patient did not pay and the doctor did not charge for these additional procedures and only billed for the hernia repair.

Optimising insurance product design remains key to keeping over-consumption in check. For example, some products favour inpatient reimbursements over outpatient even though the cost of offering the service is more expensive in the inpatient setting. Such reimbursement asymmetries should be eliminated. This is no different from how public hospitals operated more than twenty years ago – CT scans could only be subsidised in the inpatient setting. As a result, many patients were admitted for CT scans by doctors so that the out-of-pocket expenses of patients could be reduced, even though they only needed outpatient services. Public hospitals have since improved and largely eliminated such funding anomalies. Insurance companies can learn from them in their reimbursement policies and practices.

While some policy missteps and regulatory neglect may have led us to where we are now, necessitating measures to fix health insurance that may not go well with some parties, it may be timely to also revisit some old-fashioned thinking on health care and the role of government. The 1993 Affordable Health Care White Paper issued by the Government then  clearly stated “The health care system is an example of market failure” (Page 3, Executive Summary). Unfortunately, some parties may have forgotten or chosen to ignore this ageless adage.

In addition, The Government’s Health Care Philosophy was also spelled out in the Executive Summary of the said White Paper. The Philosophy consisted of 5 points, of which we reproduce here:

  • To nurture a healthy nation by promoting good health;
  • To promote personal responsibility for one’s health and avoid over reliance on state welfare or medical insurance;
  • To provide good and affordable basic medical services to all Singaporeans:
  • To rely on competition and market forces to improve service and raise efficiency; and
  • To directly intervene directly in the health care sector when necessary, where the market fails to keep costs down

(Last two points in italics for emphasis)

For a while, we had relied on the almost completely free market to manage costs in the private sector. This has obviously not worked and the government’s current moves to have fee benchmarks and to mandate the removal of first-dollar coverage riders from IPs could be perhaps interpreted as adhering to its original philosophy of 1993 – that of “to directly intervene in the health care sector when necessary, where the market fails to keep costs down”.

After 25 years, the 1993 White Paper is an oldie, and certainly in many ways, still a goodie.






NEHR: A Patient’s Perspective Through A Doctor’s Eyes

Privacy in Your Own Home? Think Again.

Imagine you owned a property you call home. It can be a simple 4-room HDB flat or a sprawling Good Class Bungalow (GCB) in District 10. You receive guests from time to time. Naturally, there are some guests you allow only to sit in the sitting room and maybe you allow them to go to the kitchen so that they can go to guest toilet in the 4-room HDB flat. But certainly, you will not let them go to the master bedroom or use the toilet adjoining it or your children’s bedrooms, unless they are very close relatives or friends. And I mean real close.

If you are staying in a bungalow with many rooms, it gets even more complicated. You may have a family room upstairs or private dining area away from the dining area where you entertain guests. The bungalow may have a study, an attic or a domestic worker’s room which guests are never welcome. In fact, you do not even want anyone other than your immediate family members to know that these rooms exist. These are very ‘private’ rooms not meant for anyone else to enter other that your immediate family members who live in this building or the domestic worker that cleans these areas. You would normally welcome guests in the sitting room or dining room where you entertain. But rarely would a guest be welcomed upstairs where your family and you share private times together.

Now serious problems arise when a bunch of people who now insist that once they enter through the doorway into your sitting room, they have a right to access every single area in the house, including your master bedroom toilet and your wife’s walk-in wardrobe as well as your study and your kids’ study. Not only that, this bunch of people want to rummage through your refrigerator and trash bin to gather information on what foodstuff you have been buying, eating and disposing.

Would you allow that? I wouldn’t. And I guess neither would 90% of people in Singapore.

But that is what the National Electronic Health Record (NEHR) does, in an analogical sense. Actually, the NEHR goes further than this. You don’t even have to allow the person through the front door. Any person who claims he has business or matters to deal with you can walk into your house and every room in your house. He is presumably “authorised”.

This hobbit understands that today, the NEHR has been rolled out in all Restructured Hospitals other than IMH. Any doctor who attends to you has a right to enter into your NEHR and see practically everything there (walk through every room in your house). There may be some small pockets they may not access (equivalent to the small safe in your bedroom) to. He can even go into your fridge or wardrobe and see what you have bought (look at your pharmaceutical record) or eaten.

And you do not even have to allow him in. He just has to claim he is your doctor. Of course, if he isn’t your doctor, that can be tracked, and the doctor will be punished. But that is post-fact. The damage is already done, your house/NEHR has been trampled all over already by the trespasser or unwanted visitor.

Privacy Rights – The Right To Control Who Knows What

The NEHR does not take into account the privacy rights of the patient in a contextual sense. There are some things I will tell Doctor A and there are other things I want only Doctor B to know. I do not want Doctor A and B and C (whom I see for different things and in different contexts) to know everything or have the same information about me.

The fact is, we all compartmentalise our lives. In our families, there are some things we tell certain family members and some things we tell other family members. Each family member often has different information or data-sets of us.  This is even applicable to close family members, such as siblings or children. Do you tell all you siblings or children exactly the same information about yourself?

The same applies in the workplace – certain colleagues know something of us that other colleagues do not. Of course, relatives and colleagues may share information among themselves through interaction but such interaction is usually coincidental, contextual and limited so that it is extremely unlikely that many relatives or colleagues have the same information about us. A simple example would be I would tell my sister certain information and I would tell my brother other information. I will also tell them they must tell no one. I thus retain privacy rights. Of course, if they betray my trust and tell each other the information they possessed without my permission, that is a breach in confidentiality (not privacy). We must not conflate confidentiality with privacy.

This is the essence of privacy rights being applied in our daily lives. As private individuals, we have the right to decide what each person knows about us through the selective disclosure of information to different parties by us. The control lies with me almost all the time, hence it is my right to privacy. It is not a privilege conferred by others. So, the latest reporting that states folks may opt-out of having their information onto the NEHR on a case-by-case basis (subject to approval) is manifestly not good enough. Case-by-case means it is a privilege conferred, not a right possessed. I have a right to privacy, not a privilege of privacy.

Of course, I do not have absolute control over privacy all the time. The elected government with the mandate of the people may take away those rights once in a while through the passing of laws. For example, the Infectious Diseases Act takes away some of these rights. Doctors have to inform MOH when their patients contract certain communicable diseases. The underlying premise is that this limitation of the individual’s privacy rights must be for a greater public good – the prevention and control of an infectious disease outbreak that affects a great many people.

However, what is the “greater public good” justification for the sharing of my medical information as a patient with all my caregivers? I would say that there is little good other than my own well-being or personal welfare. Don’t I get to decide what personal good I intend to achieve with the NEHR? Why can’t I decide what information to give each doctor or caregiver (e.g nurse)? Or even more fundamentally, If I decide to opt out completely of the NEHR, why is my doctor still forced to upload my information onto the NEHR? Yes, when I opt out, no one can access the NEHR, but that is a question of confidentiality, not privacy. My personal well-being arising from participating in the NEHR is not a public good, unlike that of the Infectious Disease Act. The decision to opt-out of the NEHR may be a medically suboptimal decision, but that is my business, not the people who operate the NEHR, as long as I know the consequences of me opting out.

NEHR: Runs Against the Grain Of Current Case Law?

It is even more confusing when you consider this in the light of the direction of medical ethics that our honourable judges are trying to steer us. The Modified Montgomery (MM) Test is now firmly established as case law in Singapore. Essentially, the MM Test firmly puts patient autonomy at the forefront of medical ethics in the country. The Chief Justice has said that patient autonomy is the “first” of the four core principles of medical ethics of beneficence, non-maleficence, social justice and autonomy.

The MM test basically says the patient has a right to decide what he wants, even if the final decision is medically-speaking sub-optimal and that the doctor’s responsibility is NOT to make that decision for the patient but simply to provide all relevant information (from the patient’s perspective) to the patient so that he can make an informed decision. An informed decision from the patient’s perspective may not be the best medical decision from the doctor’s perspective, and if the two do not match, the patient’s decision must prevail (as long as it is not against the law, such as euthanasia, surrogacy etc.). The MM test ensures that patient autonomy is expressed in its fullest sense in our society.

If that is the case with the MM test, then why are the NEHR planners and implementers forcing each patient to

  • share the same medical information with all doctors and nurses when the patient may prefer otherwise?
  • have their medical information uploaded onto the NEHR, even when the patient has opted-out?

Therefore, the NEHR as it now stands, is clearly going down the slippery slope of compromising patient autonomy.


A simple example would be, say, a married, 40 year old, working, female PMET. She would have in all likelihood most or all of the following doctors –

  • a family GP she, her spouse and her children see (who happens to be her old classmate from junior college);
  • a company doctor she sees occasionally at the workplace when she is unwell;
  • a gynae who delivered her kids and does the her pap smears and gynae checkups;
  • a breast surgeon who removed a benign breast lump a year ago and
  • an aesthetic doctor she goes to occasionally for pigmentation treatment as well as for the occasional skin peel.

We haven’t even talked about other doctors she has used whom she hasn’t any recollection of – such as the radiologist, pathologist or anaesthetist, who ALL have “rightful” access to her NEHR records as “authorised” healthcare professionals.

Do you think she wants ALL her doctors to know she has had laser treatment for face pigmentation every six months? (We are not even talking about more extensive “work” like liposuction, filler injection and breast implants, just simple laser treatment for pigmentation)

Or do you think a 45 year-old homosexual man wants all his doctors to know he has had treatment with Dr Y for anal warts excision? (He hasn’t “stepped out” yet)

Or would a 58 year-old woman who is now happily married with adult children want anyone to know she had an abortion when she was 17 (We all make mistakes when we were young, just some mistakes are bigger than others)?

Would anyone want all his or her doctors to know one is on antidepressants or erectile dysfunction drugs? Most men wouldn’t even want most of their doctors they see to know they have prostate problems, let alone be given Cialis or Viagra.

Or that all your doctors now know you have been tested for HIV before (result negative, whew) and the test is not part of a mandatory pre-employment workout?

Or that the radiology results of you, a lady, who had a fractured cheek bone as shown in an X-ray taken at the A&E 10 years ago after your then (now ex-) husband assaulted you, is now known to all doctors and nurses taking care of you now for fractured ribs, whiplash and concussion arising from a road traffic accident? Your current husband loves you, but he is wondering why he gets strange looks when he visits you in the hospital from all the hospital nurses and doctors.

Of that that a well-known 60-year-old CEO of a bank (or Professor) was once admitted to a hospital for observation after a fight and had lost consciousness and fractured his nose 40 years ago?

The list goes on and on.

What NEHR Will Contain….

In case you are wondering if these examples are realistic, well – according to the official NEHR brochure: the following information will be uploaded onto the NEHR:

  • Admission and visit history
  • Hospital discharge summaries
  • Laboratory test results
  • Radiology results
  • Medication history
  • History of surgeries or procedures
  • Allergies and adverse drug reactions
  • Immunisations

So all the above scenarios can happen in real life.

Seriously, from my personal viewpoint, I would like to share only the last two points onto the NEHR without reservation so that all my doctors and care-givers (i.e. who are “authorised healthcare professionals, according to the abovesaid brochure) can know this about me: allergies, adverse drug reactions and immunisations.

This hobbit has serious reservations about the rest, and thinks they should be handled with extreme care.


The last point I would like to deal with is that of security. Security can basically be defined as measures put in place to prevent breaches of confidentiality. How secure is the NEHR? I am confident that the planners and implementers have tried their reasonable best to ensure best practices in IT security have been put in place or are being put in place. After all, the NEHR, being backed by government, has enormous resources to do so.

Even then, no IT system, especially one that is internet-based and cloud-based, with literally unlimited number of entry points (every clinic or hospital computer that is linked to the internet is an entry point into the NEHR) is hack-proof. If it were not so, there would be no need for the government to delink civil servants’ work computers and intranet from the internet last year. It was reported this affected all 143,000 civil servants. That is a tacit admission that no security system is fool-proof or hack-proof. I suppose this shows cyberthreats cannot be wished away, but they can be effectively partitioned away.

This hobbit is sure the NEHR is as secure as can be, but not quite more secure from the civil servants’ work computers before they were delinked from the Internet. In fact, the fact that the NEHR exists must in itself be a very tempting trophy database for hackers from all over the world to try and test and breach.

In the event a breach happens and records and medical information are stolen, what is the liability of the NEHR or  the government with regard to this breach, and what are the rights of the affected patients? Can he seek redress, compensation, damages etc.?

This hobbit is unsure. These are not stated in the aforementioned NEHR brochure. Theoretically, the NEHR is exempt from the provisions of the Personal Data Protection Act (PDPA) as it is a government programme. Today, if there is unauthorised access to your data with say, your mobile phone network operator, the mobile phone network company MUST inform you so, because the company has to comply with the requirements of the PDPA. If your GP record has been hacked into today (Pre-PDPA) or physically stolen, your GP has to inform you too. You can probably sue your GP or the mobile phone network company for civil damages and the regulators can use the provisions of the PDPA to punish the GP, or the mobile phone network company.

If there is a breach of the NEHR and your record is stolen, will the administrators inform you? No one knows. Will the penalties of the PDPA apply? Probably not. Can you sue the NEHR for civil damages? Again, this hobbit really doesn’t know.


In conclusion, is the NEHR a bad thing? No. But a lot of work needs to be done with the NEHR as it now stands; beginning with:

  • We need to discuss openly about the potential downsides of the NEHR as the NEHR currently stands and not just only extol the positives of NEHR.
  • We need to recognize that privacy rights need to be adequately addressed. The patient has to retain the power to give and retain information to the healthcare professionals or settings as he sees fit. It is natural to compartmentalise our lives and our interaction with people, and this compartmentalisation extends to the healthcare realm. You cannot talk about confidentiality and security without settling the issue of privacy rights first.
  • We need to clearly spell out the rights of the patient and the responsibilities and  liabilities of the NEHR owner(s) when there is a security breach. Some sort of a patient charter should extend to the realm of NEHR too.

And we are only talking about looking at the NEHR from the patient’s perspective. We haven’t even talked about the NEHR from the perspective of the people who record and use the information – the healthcare professionals.

A reader of this article may well ask “The typical or average patient in Singapore will in all likelihood not know the issues this article has raised and will not be concerned as such”. It is because this Hobbit is a doctor that he can understand and bring up issues such as privacy, confidentiality and security which dogs the planning and implementation of NEHR.

But that is besides the point. We are actually all in the same boat as “patient advocates”, working for the patient’s best interests and betterment of patient’s well-being: politicians, civil servants, IT experts, healthcare professionals such as doctors, nurses etc., and of course the patients themselves. If we are sincere and serious about being patient advocates, then the questions raised in this article need to be communicated to the public, recognised, considered and addressed by all stakeholders. These issues cannot be ignored, dismissed or simply swept aside if we truly work in the best interests of the patients from a holistic and comprehensive perspective.

The residency rollout was one bad example where those in power then were dismissive of the issues and reservations raised. They steamrolled ahead and adopted the ACGME-I system and the results are for all of us to see now. It is still early days, the NEHR need not go down the same  painful route as residency.


Not the APHTEC Accounts

NOT the AHPETC Accounts
Hello folks. Time really flies and it’s already October, almost a month after the last General Elections where important national issues such as whether Paul Anath Tambyah’s admiration for the similarly trichologically-challenged DPM Tharman was misguided or if Tin Pei Ling will get make-up maternity leave were never discussed. Instead, there was a lot of talk about the AHPETC accounts. For those of you who live on Pluto and therefore do not know what it stands for, this Hobbit is happy to tell you that AHPETC stands for “Anyhow Hantam People, Everyone Totally Confused”. Thankfully, going forward, it is only AHTC, which stands for “Any How Talk Cock”.
But this month’s column is not about the AHPETC accounts, which have been dissected to death, much like my A levels biology laboratory cockroach.
For those of you who get a high from looking at numbers, there is juicier stuff than the AHPETC accounts. We are talking about the Singapore Medical Council (SMC) accounts. For the avoidance of doubt, there is absolutely nothing mischievous or unreliable about the SMC accounts, which are unqualified by the auditors. For those of you who are uninformed about how the accounting and auditing profession works, here’s a simple summary:
· “Unqualified” accounts is good, “qualified” is bad. This is completely different from how the medical profession works of course, where the unqualified practice of medicine is basically quackery and qualified means you have to pay SMC money eight hundred bucks every two years and attend CME. And can you blame people if they are confused about the AHPETC accounts. Remember – in accounting, unqualified is good.
· Accounts have to be “true and fair”. This true and fair concept is fundamental to the whole practice of audit. Accounts must be “true and fair”. But there is no mention of accuracy. So the standing joke among accountants is that accounts have to be true and fair but they need not be accurate. Contrary to public perception, accountants do have a sense of humour and some of them even have biological processes like micturition and defaecation.
With these two important points in mind, let us now move on to the matter at hand – SMC accounts. The published accounts are reliable because they are true and fair and unqualified.
First of all, this hobbit would like to thank and praise the current SMC administration for finally publishing the financial accounts in the latest (2014) Annual Report. Light is the best disinfectant and the act of publishing the accounts is illuminating.
The first red flag that screams out to you in the financial statements is that SMC is in the red. It is more in the red than Paul Ananth Tambyah and Chee Soon Juans’ polo-shirts put together. In fact, it is redder than all the red ties that the entire Cabinet wore at last evening’s swearing-in combined. It is so red, it makes my Alexandra Village ang-gu-kueh look anaemic.
In the Statement of Comprehensive Income (which is a fancy, new name for Profit and Loss Accounts) on page 63, it is reported that SMC made a loss of $2,607,382 against a total income of $5,206,951. In business, people talk about profit margins. For example, if you made $1 out of a revenue/income/sales of $10, the profit margin is 10%. The other side of the coin is the loss margin.
In the case of SMC, the loss margin is $2,607,382/$$5,206,951 or 50%! In simple layman terms, it is like a household that is living way beyond its means – it is spending $3 for every $2 it makes. If this was a company, the CEO, CFO and just about the entire senior management have to ask some very serious questions about their own existence. The board of directors and shareholders too have to ask themselves whether this company needs some very serious restructuring. If this was a publicly listed company and this situation persisted for say, 3 years, the stock exchange and auditors may even have to ask if this company has an issue of being “an ongoing concern”.
But thankfully, the SMC is a statutory board and its existence is guaranteed, as its name suggests, by statute (law passed in Parliament). As Minister Lim Swee Say would say, “Heng ah”.
But the losses are real. SMC is still spending $3 for every $2 it receives. One gets more information into this situation when you delve deeper into the Notes to the Financial Statements. In Notes 15 and 16, Employee Compensation came up to $5,365,442. This is against the background of Total Income of $5,206,951 and Total Expenditure of $7,814,333.
In other words, total manpower costs ALONE was more than the total income for SMC. This excludes all other operating costs, like utility costs, legal costs, rental etc. Again, if this was a company, it is a very scary situation. Can you imagine if you clinic’s salary costs alone is more than the total revenue of the clinic?
The next biggest chunk of costs is legal expenses (Note 14). The picture is summarised as follows:
· Legal Expenses $1,757,484
· Legal Proceeding Cost Recovered: 964,119
· Nett Legal Expenses for Disciplinary Proceedings: 793,365
IF we momentarily ignore the recovered amounts (i.e. in which SMC ordered the guilty doctors to pay legal costs incurred by SMC), the total amount of money spent by SMC on law firms is $1,757,484. That’s a lot of money. Had we spent the money procuring legal advice or manpower from the government instead, SMC could probably have comfortably asked for two to three superscale legal officers (equivalent to partners in a law firm) and three to four time-scale legal officers (equivalent to junior lawyers or legal assistants in a law firm) from the Legal Service and ample administrative support working full-time for SMC. And if you consider the point that the Disciplinary Tribunals, Disciplinary Committees and Health Committees only heard a total of 23 cases in 2014, one must consider if SMC could have shaved substantially off the amount of $1,757,484 had it not engaged lawyers but government legal service officers instead to advise it. How many legal service officers do you need to handle 23 cases a year? And how much would the legal service charge SMC on a cost-recovery basis? And it is not as if though SMC is getting sterling advice and services from the lawyers it engages, judging by some of the recent remarks judges have been making in some of the appeal cases that they have heard.
Other cost items that bear mentioning are that for Computer Operations and Maintenance: $597,409 (Note 15). That’s a lot of money if you consider it comes up to 11.5% of the total income of SMC or 7.6% of expenses/costs. Most organisations or institutions do not spend around 10% of their revenue or costs when IT is really not their core business; and it is just to operate and maintain an IT system.
An interesting point to note is that SMC has “Sundry Receivables” (Note 20) of $2,290,755 (FY2015) and $2,005,703 (FY2014). This is not a bad thing if the sundry receivables are indeed recoverable (and there is no reason to suggest that it cannot be). But since SMC is not a sundry shop, this Hobbit hopes the Notes to the Financial Statements in future can describe what these sundry receivables are since this item takes up a hefty chunk of the income/revenue.
SMC’s rental for FY2105 came up to $405,887. That’s not really a lot if you think of the size of the offices but then again when you are so in the red, maybe it’s time to consider a cheaper place than College Road. Or maybe a smaller place?
Finally, let’s have some good news. The good news about SMC is that it has got cash and assets. The Balance Sheet of SMC shows that it has Current Assets of $13,897,777, which includes cash and fixed deposits of $10,351,568. But SMC also has liabilities that have to be met or paid. The leftover “equity” or “Accumulated Fund” came up to $6,135,670. If we make an assumption that SMC continues to make a loss of about $2.5M a year, the money will last us about 2 years and 5 months. After that, SMC runs out of money. (OK, I was kidding about the good news bit..)
So SMC has about 2 years to turn this situation around. This can happen by doing a combination of three things:
· Cut costs
· Raise revenue by raising subscriptions from doctors
· Raise grants from the government
Cutting costs is the most obvious thing to do, as we have described above. And it has to do with manpower costs, legal costs and computer system operations and maintenance, since these are the big ticket items. The rest wouldn’t move the needle much.
Raising revenue, whether from the government or from doctors, should not be done until SMC has shown it has done all it can on cutting costs without jeopardising the mission of SMC, which is the upholding of medical ethics and professionalism in Singapore. Because whether you take doctors’ or the taxpayers’ money, we need to see good accountability and stewardship from SMC.
In any case, just for everyone’s information, MOH grants only came up to $19,260 in FY2014 and zero in FY2015. So big daddy isn’t about to give SMC a blank or big cheque anytime soon.
Which brings us back to SMC being a statutory board where the majority of members of SMC are appointed by the government and not elected by doctors. Since that is the case, perhaps the government can at least fund 50% of SMC’s operations from MOH’s budget?

Pioneer Generation Package

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.

What NOT to Spend 7.1 Billions Dollars On…..

What NOT to Spend 7.1 Billion Dollars On……

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…..

Another White Paper

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.


“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.

Top 10 Questions Related to SMC Best Left Unanswered for 2012

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 😉

CHAS and Community Pharmacies

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 see ). 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….