Category: General

SG60: What if……

As we celebrate our nation’s 60th birthday, perhaps it is time also to think what may happen in the next 60 years for doctors living on this island. Certainly, the medical profession has come a long way since 1965. The profession’s trajectory has been largely a positive one, both for itself, the country and the community it serves.

We have become bigger and more complex. Each year, thousands of applicants vie for the 500 or so places in our medical schools. Another 200 come from foreign universities. Taking into account retirements and deaths, our ranks have increased by about 600 to 700 a year in recent years. We have grown to 35 specialties and 10 subspecialties.

But do these numbers mean that everything is hunky dory down the road for the next 60 years or even just the next 10 to 20 years?

Let’s ask a few questions (which will NOT be answered in this column):

  1. What if doctors are no longer trusted by the public and held in high esteem by society?
  2. What if our medical schools no longer attract the brightest to apply?
  3. What will happen if only the rich can afford to send their children to our local medical schools?
  4. What if there are significant numbers of doctors who cannot get a well-paying job after they finish their housemanship or their 5-year government bond and most of our young doctors no longer think Singapore is a good place to work and make a living and go elsewhere to practice medicine and raise their families?
  5. What if defensive medicine takes root and becomes pervasive in Singapore?
  6. What if two-thirds of our doctors quit public service and go into private practice? (Presently, the converse is true: roughly two-thirds of the medical profession work in the public sector)
  7. What if the medical profession loses our professional independence and practice in a way that is dictated by other parties with different priorities, such as insurance companies and third-party administrators?
  8. What if we are no longer seen to be a country that can offer the most advanced medical services in the region and regional competitors have surpassed us in capability and skills and Singaporeans have to go to a neighbouring country to get access to advanced treatment modalities and highly skilled doctors?
  9. What if large numbers of doctors no longer believe it pays to be ethical because making a living as an ethical doctor is just too difficult and unrewarding?
  10. What if the majority of doctors can no longer afford private housing or own a car at even say, 40 to 45 years-old?

These are uncomfortable questions to which we instinctively know the answers to, but which are difficult to say aloud, especially to non-doctors. What is more, many of these 10 questions are actually interlinked or correlated.

While we have every reason to be thankful these 10 questions are really hypothetical in nature now, we also always need to be alert and to guard against the possibility that the answers to these questions becomes reality in Singapore.

Happy SG60!

About That $52,000 Rental Bid

About that $52,000 monthly rent…

The hottest topic on both the mainstream media and internet lately has been that HDB shop-lot in Tampines that attracted a successful bid of $52,188 rental a month.

Minister for Health Mr Ong Ye Kung expressed dismay at this outcome and said ultimately it would lead to “higher cost of healthcare one way or another”. More importantly, he noted that “higher rental bids do not necessarily translate to the best healthcare that the community needs”. (4 June, Facebook post).

He went to restate what has been previously reported in the news: MOH is working with HDB to launch a new tender system such that quality of care accounted for 70% of the tender evaluation, and rental price accounting for the remaining 30% with Bartley Beacon, another HDB estate.

Obviously, the recent trend of rapidly and sky-high rental bids has not gone unnoticed by MOH. In February 2024, a 2nd-floor clinic space, also located in Tampines (633 Tampines North Drive 2), attracted a successful bid of $39,938 rental a month. And if you think this is an outlier, the answer is negative. The next two highest bids were $39,888 and $36,138 respectively.

In January this year, a clinic space at Tengah went for a rental bid of $40,088. As you can see, the trend is ominous. So, getting to $52K today is something that is while “obscene”, (To quote Dr Hishamuddin Badaruddin, the doctor who originally made public this figure on his social media account) but hardly unforeseen.

Another interesting factoid is that these new HDB shop-lot are about 550 square feet in size, which is about 100 square feet smaller than shop-lots launched say, 20 years ago. Older HDB estates commonly have shop-lot sizes between 650 to 700 square feet. This loss of 100 square feet is about the size of a small consultation or procedure room. In other words, whereas in the past you can squeeze in two consultation rooms and a procedure room in to the HDB shop-lot, you probably can’t do that with 550 square feet. So, the assertation that the high rental is workable because you can have two doctors working in two consultation rooms simultaneously is a stretched one; what if suddenly an asthma patient needs a nebulizer? Are you going to neb him in the waiting area with the other patients? Or neb him in your consultation room and you suspend patient consultation in the meantime?

But the larger issue besides such operational ones is what is the role of the market and market forces in healthcare? In one corner, you have the “purists” who maintain that market forces will allocate resources most efficiently through the forces of demand and supply. So, $52000 rental is not a problem. The market will work itself out and everyone will live happily after. In the other corner, there are those who think the healthcare sector needs to be managed, and sky-high rentals do not lead to good outcomes for the public that requires such services.

But what does the Government say? Or at least, what did the Government used to say?

In 1993, the Government published a White Paper titled, “Affordable Health Care”. The White Paper was the work of a Ministerial Committee on Health Policies. The Committee was originally chaired by then Deputy Prime Minister Lee Hsien Loong followed by Minister Mr Dhanabalan, and its members were several Cabinet Ministers and Ministers of State.

Notably, right from the outset of the White Paper, this was stated, “Any healthcare policy has to trade off among four competing goals

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

No known health care system achieves all four goals simultaneously. A system can achieve three of them with some compromise. Which three to aim for depends on the prevailing social, financial and political conditions. Given Singapore’s environment, we have to compromise the last goal: freedom to organise production and price”.

(page 13, Affordable Health Care)

The Paper came up with a “Proposed Health Care System” that entails a “hybrid approach to controlling health care costs: neither to create a totally regulated national health service, nor to give providers full freedom to organise and to price health services in a completely free market”.

(page 14, Affordable Health Care)

Moreover, it was also stated in  Chapter 2 of the same Paper “Health Care Philosophy” that “health care is an instance of market failure” (page 18).

Let’s now look at what happened when we let unbridled market forces determine our fate.

In 2008, the government tendered out a piece of 99-year leasehold land for the building of a private hospital. Since then, no land has been released for this purpose in Singapore. The tender was awarded on 18 February 2008. It involved a site area of 12,226 square metres yielding a Gross Floor Area (GFA) of 72,350 square metres or 778,775 square feet. The successful bid was $1,246,200,389. For those of us not accustomed to counting so many digits, that’s ~$1.25B or $1,600 per square feet of floor space. This was and I believe still the most expensive piece of hospital land ever sold. The hospital today standing on that piece of land is Mount Elizabeth Novena Hospital (MENH). If my memory serves me correctly, the 2nd highest bid was about half of this figure.

This is the free market at work. And by winning this bid, Parkway Hospitals (then) managed to maintain its dominant position in Singapore’s private hospital segment. But in the process, as most of us doctors will know, it also probably contributed to more healthcare inflation once the high land cost of this project was factored in. The total project cost was probably somewhere between $1.5B to $2B, once you include construction, equipment and commissioning costs. And this was more than 10 years ago.

This high land price has far-reaching consequences for us even now, some 17 years later after that momentous tender exercise. It probably also set a new benchmark for private hospital land in Singapore. In government land tenders, the Chief Valuer sets a secret reserve price for the piece of land being tendered. If all tenders come in below the reserve price, then the tender is not awarded. This non-award of tenders because all tenders came in below the reserve price has happened before.

One wonders, what will be the reserve price for private hospital land now, if a new tender is called? Can a new hospital operator come in to this market segment since the reserve price is certainly influenced to some extent by precedents?

Thankfully, this situation of a very high bid affecting subsequent tenders does not apply to this $52,000 bid. HDB has clarified that “The rental for this Tampines clinic does not set any price requirements for future tenders by HDB, and it also will not affect the rentals that HDB is charging other existing clinics,”.

Unfortunately, no government official has said the something to the same effect for private hospital land.

It is worth repeating here what those wise people wrote in 1993 in the Affordable Health Care White Paper,  “health care is an instance of market failure”.

How You Pay Affects How Much You Pay (and How Much Taxes We Pay)

Last month, DPM Gan Kim Yong and Health Minister Ong Ye Kung gave an interview to The Straits Times’ Ms Salma Khalik (Healthcare financing in Singapore: 10 Questions for DPM Gan and Health Minister Ong, 10 April 25). These are two persons who collectively have run MOH for 14 years and they really know what they are talking about.

But for the avoidance of doubt, the serious smart money is on the interviewer, Ms Salma Khalik, who has been covering health for ST since BC times (Before Clustering) and possibly even before there was Internet and the smartphone. This hobbit thinks only Senior Consultants can safely claim they were already born when she started covering health matters for ST.

A few things struck me in that interview, which includes lightning, since it was so near to the General Elections 2025 when the interview was given. The first notable point is that by 2030, the MOH Budget likely to approach the eye-popping figure of $30B. To revisit the first of Minister Ong’s two truisms of healthcare which he mentioned last year in Parliament (6 March 24) – the people always pay. This $30B will be paid by the taxpayers, since MOH Budget is mainly funded by government revenue.

Another important point made in the interview and also previously on other occasions is that one in two persons with Integrated Shield Plans (IPs) and riders opt for subsidised care.

These two points are worth mulling over especially in the context of Minister’s Ong’s second truism – How you pay affects how much you pay.

Personally and selfishly speaking, I do hope that people with IPs and riders do not opt for subsidised care. The logic is simple: – subsidies are always paid by every taxpayer, and that includes me. But if folks use more insurance to pay for their healthcare expenses, then the taxpayer pays less. It’s almost literally a zero-sum game because insurance is funded by policyholders and returns from investments by insurance companies using the premiums collected.

However, whenever folks do NOT utilise their IP entitlement and go to the subsidised classes, taxpayers end up paying most of the bill. Even for B1 class, taxpayers pay because B1 class is subsidised a bit. Only A class is unsubsidised.

The next question to ask is then why are so many people with IPs and riders opting for subsidised care? There are many reasons but one of the most often quoted reason is that they worry about difficult access to subsidised care after a hospitalisation or procedure. Current IP plans all cover the patient at the outpatient level only for a very limited period after a hospitalisation or a procedure. After the coverage expires, the patient has to pay the expenses himself. And once a patient opts for private hospital care or A or B1 care in the restructured hospitals, he will continue outpatient follow-up care with either private specialists or the private (unsubsidised) clinics in the restructured hospitals. Many such conditions are chronic ones and they require a long, if not life-long, outpatient follow-up and many people need subsidies due to the high cost of such long-term follow-up.

The end result is that many people then opt for subsidised care despite having bought IPs and riders so that they can avail themselves to these subsidies during follow-up.

To better understand this flight to subsidy safety among IP policyholders with riders, we can conceptually divide policyholders into three groups:

• Group 1: Folks who will always use private sector services for inpatient and outpatient care
• Group 2: Folks who will select between private sector and subsidised services depending on insurance coverage and subsidy policy
• Group 3: Folks who will always use subsidised care (basically, they didn’t really know what they were buying when they bought an IP)

For the avoidance of doubt, “private sector services” refer to services that are completely unsubsidised – private sector hospitals and clinics and also A class inpatient and private (unsubsidised) specialist clinics in restructured hospitals (RH) since the latter do not consume government subsidies.

The 2nd group is what concerns us today. As aforesaid, because of the bundling of subsidised inpatient care with subsidised outpatient care, many policyholders forgo the use of private inpatient services so that they can enjoy subsidised care during follow-up. And as our population ages, the follow-up of chronic conditions discovered during before or during an inpatient episode can be for a long time, if not life-long.

This results in unnecessary consumption of the MOH Budget (i.e. taxpayers money).

This policy has been in place for a long time because policy wonks are worried that folks will game the system. I.e. these folks want the best of both worlds: by consuming inpatient services paid for insurance and then using subsidised services when insurance coverage ceases. But in reality, as we shall see, this worry has been downgraded somewhat in recent years.

If one thinks about this again, by continuing with this policy or practice, many people end up using subsidised, inpatient services unnecessarily which generally speaking, are a lot more expensive to the taxpayer than outpatient services. Again, we have to remember it is better if policyholders finance their healthcare needs with insurance monies than with tax revenue.

However, if we truly allow patients to cherry-pick (by using insurance-funded inpatient services and taxpayer-funded subsidised services), then a problem will arise with the first and second groups. The attraction of subsidies is so great that some folks in these groups will migrate towards outpatient subsidised services.

There is already some pre-existing friction put in place to discourage this because one cannot choose the specialits of his choice in subsidised services, whether inpatient or outpatient. Also, appointment times for private SOCs are significantly shorter than subsidised SOCs. But this hobbit readily admits this friction or obstacle is not really big enough to prevent overconsumption of subsidised services. Further trade-offs may be therefore necessary.

Moreover, access to subsidised specialist outpatient clinics (SOCs) and services have been made much easier in recent years with the CHAS, Pioneer and Merdeka Generation benefits. It used to be that only polyclinics and A&E referrals will give a patient access to the subsidised SOCs. But now any Healthier SG family physician can make referrals to the subsidised SOCs and their patients will enjoy subsidy levels according to their CHAS, Pioneer, Merdeka Generation card status. This is what I mean when I say the worry of overconsumption of subsidised services have been downgraded somewhat in recent years.

This hobbit doesn’t have the data, but it would be good if someone with the data does a simulation on how much of the MOH budget is used to finance subsidised inpatient cases that come from IP policyholders who voluntarily downgrade at the inpatient level. These are the potential savings from that could have been realised if inpatient subsidies were not doled out to this group.

This hobbit would like to suggest that to reduce the number of IP policyholders voluntarily downgrading to subsidised services without using their IP benefits, it is worthwhile to just allow IP policyholders to choose a private service for an inpatient stay and then let them have the option of choosing subsidised SOC services when they go for follow-up. If the policy wonks are worried that this would lead to everyone choosing subsidised SOCs, then we can perhaps strike a compromise – we would limit this option to conditions that had been newly diagnosed (i.e. just before or during the inpatient stay) for the purposes of this inpatient or procedural episode.

For example, if a patient goes for a Total Knee Reconstruction (TKR) at a private hospital or as a Class A patient in a RH, but is diagnosed to have diabetes just before admission as he is being assessed by the anaesthetist, then he should be given the option after the operation to be followed up at the subsidised SOC at a RH. The subsidised SOC can then decide to follow-up this patient or discharge him to the polyclinic when his diabetes stabilises.

Today, certain RHs already allow for downgrading to subsidised SOCs after B1 or A class inpatient episode. But to further discourage unnecessary downgrading, we should maybe allow private hospital inpatients (not just RH’s inpatients) to use subsidised SOCs as well after IP coverage expires.

If the patient or IP policyholder is given this optionality of delinking outpatient subsidy from the inpatient episode, we can perhaps get more IP policyholders to use their IP benefits at the inpatient level and rely less on funding via subsidy, i.e. how much the government or taxpayer pays.

Andy Lau and the Demographics Behind The Figure of 63%

Recently, clips of a speech by Minister for Manpower, Dr Tan See Leng went viral. It went viral because he quoted from a 2004 Cantonese movie called 江湖 (“Blood Brothers” in English) starring HK heavenly kings Andy Lau and Jacky Cheung, in the recent parliamentary Budget debates. It is a movie about the HK underworld triads and both the heavenly kings were cast as triad bosses. The lines from the movie were used to chastise Non-Constituency Member of Parliament (NCMP) Leong Mun Wai from the Progress Singapore Party (PSP) for repeatedly trying to get data that differentiates between citizens who were born in Singapore and citizens and PRs who were born elsewhere.

Whether you agree with the Minister or not, this hobbit must concede that the incident was quite funny. And it was in Cantonese. This hobbit did not think he would live to see the day when Cantonese would be uttered in Parliament ever since Chinese dialects were banned on national TV in 1979. The first HK TV Cantonese serial that was dubbed into Mandarin in Singapore happened in 1979. The serial was the version of Heaven Sword and Dragon Sabre starring Liza Wang and Adam Cheng (both of them are 78 years’ old now). Yes, this hobbit is that old. I don’t call myself an “old coot” for nothing.

The parliamentary speech segment was so funny that The Straits Times came up with an official English translation the next day. It reads “Even if I’d said it, you wouldn’t listen to it. Even if you’d heard me, you wouldn’t understand. Even if you understood, you wouldn’t do it. Even if you did it, you would do it wrongly. Even if you did wrong, you wouldn’t own up to it. Even if you owned up, you wouldn’t correct yourself. Even if you corrected yourself, you did so begrudgingly. Then what am I supposed to do?”.

This is seminal because for once, parliamentary debate is funny. It hasn’t been so for a long time. Let’s face it, our political leaders just aren’t that funny. And we could all do with more laughs once in a while. Humour is in itself an effective communication tool.

But jokes aside, the important fact that was revealed by the Manpower Minister before he quoted Andy Lau was that 63% of newly created PMET (Professional, Managerial, Executive or Technical) jobs went to local-born citizens.

The PSP NCMPs (Mr Leong and Ms Hazel Poa) then replied over the next two days that there were right to insist on demanding on the breakdown between “old” citizens and PRs (born in Singapore) and “new” citizens and PRs (not born in Singapore) because all the new jobs created could have gone to new citizens and PRs and so there was no benefit to old citizens and PRs. Ms Poa gave a table of figures to illustrate this possibility. This hobbit is told Ms Poa studied Mathematics at Cambridge University and the table is of course 200% correct. (it’s 200% because this hobbit didn’t study Maths in any university).

Mr Leong came up with a Cantonese clip of his own to rebut the Minister. I must say the way he spoke Cantonese was really old school and slick. He reminded me of this famous and handsome actor called Cheung Ying (张瑛) who acted in many classic black and white HK movies from the late forties to the sixties. He died in 1984 and in addition to his acting, he was also known for having had five wives in his lifetime.

But we digress.

This hobbit has no wish to take part in partisan politics because politics is nice to read about but terrible to participate in. Especially the partisan kind. So, this hobbit will not comment on whether 63% is too high or low or whether we should really distinguish between old or new citizens and PRs. But this hobbit readily confesses that all his grandparents weren’t born in Singapore. And he also confesses that he grew up watching movies starring Cheung Ying replayed on TV, in particular on Channels 8 and 10 (The then free-to-air Malaysian channel).

However, demography is something that is taught in medical school (at least when I attended medical school) and this hobbit would like to offer a perspective from a demographic angle.

It is well known that the Total Fertility Rate (TFR) of Singapore has fallen to slightly less than 1; 0.97 to be exact. The number of “resident” babies born in 2024 was 30,800 (babies with at least one parent who is a citizen or a PR). The replacement TFR acknowledged worldwide is 2.1, which is when the population replaces itself with no increase or decrease in population size. Let’s round up our latest TFR to 1 and round-down the replacement TFR to 2.

The replacement cohort size for residents would therefore be 30,800 x 2 = ~61,600, give or take a few. Another fact to note is that for the birth cohorts that are now in the workforce, the cohort sizes were bigger, probably ranging from 40,000 (Millennials and early Gen Z) to >60,000 (Gen X and late baby boomers). In recent years, we have maintained or grew Singapore’s resident population size by maintaining the cohort size of about 60,000 or more per birth cohort through immigration – i.e. by converting non-Singapore born PRs to citizens and giving out PRs to foreigners.

Personally speaking, I do not want the resident population to shrink, as we are already seeing the ill-effects of this phenomenon in places such as Japan. And as a selfish old coot, I would like to see more young people working and paying taxes to fund folks like me who are retiring or have retired. I also do not want to increase the resident population too much too quickly, because this in itself may drive inflation higher and create a very crowded living environment.

But if we are to just maintain the resident population (no increase) and with the resident cohort size continuing to shrink in the more recent cohorts to the now all-time low of 30,000 resident births or so, the government of the day will have to top-up the shortfall with more and more “new” citizens and PRs who were not born here. So going forward, the figure of 63% is almost certain to drop further to 60% or even 50%. Since we have a TFR of 1, it is also very likely that the figure of 50% will be reached in the future, provided our number of resident births do NOT decline further. If it drops to 20,000 births a year, and the replacement cohort size remains at ~60,000, then the figure may even hit a shocking 33%. I.e. Singapore-born citizens only take up ~33% of the new PMET jobs created.

It’s simple maths.

This is a mathematical and demographic certainty if we want to maintain (or maybe even grow slightly) the resident population. Barring the most unlikely scenario of our TFR miraculously rebounding back to 2.1, the figure of 63% will only rise (i.e. >65%) if we are happy to see the resident population shrink or if we are happy to attract new citizens and PRs who take on non-PMET jobs or both, assuming that the number of new PMET jobs being created remains the same over time.

All this is beyond the small brain of this hobbit. But from a mathematical and demographic perspective, the figure of 63% will not, in any likelihood, get any higher, so don’t hold your breath for that to happen. It’s got nothing much to do with favouring new citizens and PRs over old ones but more to do with the lack of resident babies to maintain the resident population. It is essentially a demographic problem. The additional underlying considerations could also be about maintaining or growing the absolute size of the economy (i.e. GDP); as well as the relative contribution by residents to our economy vis a vis foreign workers’ contribution (i.e. those holding Employment Passes, S-passes and Work Permits).

But of course, none of this really matters to the man in the street who has lost his job and is looking for another job without success and to the new graduate still jobless six months after graduation. Which is why this hobbit is pretty sure that Andy Lau and Jacky Cheung are having a better time than our Manpower Minister now. Not to mention Cheung Ying, who had five wives.

What Our Healthcare Can Learn From DeepSeek

This hobbit came along this article in The Straits Times recently, “How did DeepSeek build its AI with less money?” by Cade Metz. The original article was first published in New York Times on 12 Feb 25.

Some points mentioned in this article hold lessons for us working in healthcare and is certainly worth mulling over by the big shots who design and implement our health care systems and policies.

The overarching theme of DeepSeek’ success was that it achieved just as much by using less. The big American AI companies typically used 16,000 specialised chips (i.e. Graphics Processing Units, or GPUs, produced mostly by Nvidia) to train their LLM (Large Language Model) chatbots. DeepSeek only used about 2000. In doing so, it saved on a lot of resources, including not just chips, but energy as well, because these chips consume a fiendish amount of energy and sending data between these chips consumes even more energy. Such activities release a huge amount of heat in the process. These chips are housed in huge data centre buildings that produce so much heat that they need another building to cool the data centre building.

The article claimed that DeepSeek’s “engineers needed only about US$6M in raw computing power, roughly one-tenth of what Meta spent in building its latest AI technology. It is no exaggeration to say that DeepSeek has demonstrated a quantum leap in efficiency that has completely changed the game in town. Here are a few lessons we can learn from the development of DeepSeek that we can perhaps consider for healthcare:

Lesson 1 – Spread out the work, pair the expert with the generalist

The first strategy and technology DeepSeek employed was to use a method called “mixture of experts”.

“Traditional” (if there is such a word) AI companies employed a single neural network to learn literally everything under the sun. This monolithic approach takes many chips, time and energy. The designers of DeepSeek split the system into many neural networks, each learning one area of expertise. Each smaller neural network concentrated on one particular field. In itself, this is nothing special. What made DeepSeek special was the designers then paired these specialist neural networks with a “generalist” system. This generalist system then helped to coordinate interactions between the many expert neural systems.

Now, it is not uncommon for a single patient, whether inpatient or outpatient, to generate several referrals to other specialists in the hospital or specialist outpatient clinics. There is no generalist involved. Once the polyclinic or family physician makes a referral to the specialist or hospital care system, the patient is then often stuck in the environment for a long time, if not forever. There is no generalist coordinating care there or interactions between specialists. The family physician or generalist only coordinates care when the patient leaves the hospital system. Perhaps we can consider having generalists in the hospitals and specialist outpatient clinics to coordinate care and cut down on unnecessary processes that consume lots of time and resources.

Lesson 2: Do not aim for perfection

We are told that the training of AI neural networks basically relies on multiplication of numbers: “months of multiplication across thousands of computer chips”. These chips pack their numbers into 16 bits of memory. But DeepSeek developers managed to squeeze these numbers into only 8 bits of memory, thereby lopping off “several decimals from each number” and saving a lot of memory space in the process. The answer so produced was less accurate but it did not matter. The article stated that “the calculations were accurate enough to produce a really powerful network”.

But that’s not the end of this story. One now has to multiply all these 8-bit numbers together. DeepSeek now stretched the multiplication answer across 32 bits of memory, and in doing so, made the answer more precise. Which is why DeepSeek performed just as well if not better in certain areas that other AI platforms consuming far more resources.

In healthcare, doctors and other healthcare professionals are reminded that we owe the patient a duty of care. Arising from this duty is the concept of standard of care. What is the standard expected of us in every instance of care we deliver? This used to be determined by our peers, but somewhere along the way, the concept of “best practice” crept in.

Best practice is laudable and of course something we should aspire to give. But does the required standard of care necessarily equate to best practice? This hobbit thinks not but many others think so. When a doctor is found wanting in a disciplinary inquiry, the standard of care quoted is often best practice. And when what was done does not quite qualify as best practice, the doctor can be found to be guilty of negligence or professional misconduct etc.

For example, should a doctor be punished when he did not see the patient personally but relied on his registrar’s assessment, (even though he did see the patient eventually, albeit 12 hours later), or when he did not order a CT scan one day earlier than when he actually did, and relied on blood tests and an erect Chest x-ray in the meantime to detect an intestinal perforation? Somehow along the way, our medico-legal environment has conflated required standard of care with best practice, the equivalent of the 16-bit number, when what is needed (or what we can afford) is really the 8-bit product.

We need to learn that “good enough” care is what we should be delivering most of the time, especially in situations where resources are limited and public funds are used. Of course, when one is paying for their own care out of their own pockets and if they can afford it, they can ask for best practice care all the time. Elon Musk and Jeff Bezos can ask for and pay for best practice care all the time. But in reality, most of the time and for most people, “good enough” care is all that the person or the system can afford.

This can also be seen in how we choose our healthcare IT systems. Do we have to choose the most comprehensive (read: expensive) system with all the bells and whistles that costs not just an arm and a leg but all four limbs to implement and maintain? When most of the time, these additional features are either not required or used at all? Why should we choose the most “perfect” IT system for our hospitals? Could we not have settled for less, i.e. settled for an 8-bit product and not 16, and maybe tried to stretch the output to a 32-bit after we are familiar with the system? Could we not have chosen a good-enough system instead of the best system?

Lesson 3: Prioritise your work

Not mentioned in the aforesaid NYT or ST article but mentioned elsewhere is that DeepSeek uses a new way of prioritizing data which uses far less memory space than older methods. This is known as Multi-head Latent Attention (MLA) as opposed to the traditional Multi-head Attention (MHA) method. MLA has been demonstrated to use only 5 to 13% of what MHA uses and in doing so, allows for far more efficient training and deployment. The multiplications we mentioned earlier results in much data produced. These data are stored in the form of fundamental data structures known as Key-Values, (KVs) which are then stored in the memory cache.

MLA allows for low priority KVs to be compressed into what is known as latent vectors and in doing so, MLA reduces the KV cache size dramatically. When these low priority KVs are needed, they are decompressed again for use.

Sometimes in healthcare, we attempt too many things at once. Our in-trays (physical or virtual) are loaded to the brim with different things that demand our attention at the same time. They can range from service requirements to teaching responsibilities to research projects. The myriad of demands we make on the system and on our healthcare professionals, in the end creates so much complexity and consumes so much attention that the system slows down or even gets paralysed.

Another good example is how we structure our subsidy system with layers and layers of schemes that makes things so complex that our hospitals’ IT and billing systems cannot cope. The result is slower and unsatisfactory performance of both the staff and the IT systems.

We could perhaps look at all the balls we are trying to juggle in the air and prioritise the work. Schemes that have marginal impact would be merged or even dispensed with altogether. Focus on only the few things that matter. Often, a person or an institution cannot be good at all things all at once. Less important things need to be compressed and cached, maybe even disposed.

If your institution’s waiting time is now a year, perhaps it is time to focus on service delivery and minimize other non-essential stuff. Getting your doctors to run ad-hoc clinics can help in the short run, but it may not help in the long-term, as job satisfaction decreases and more people quit, leaving the organization in a vicious cycle of attrition and more work. It is far better to prioritise your work (and your people) and cut back on the non-service delivery work. Compress and cache these non-essential work for now.

The above are just three simple examples of how we can learn from DeepSeek. There are many others. The underlying principle of why DeepSeek is revolutionary is that its developers experimented with solutions to real problems and obstacles. The solutions they tried are not just incremental in nature or doing more of the same thing. By many accounts, most of the folks who worked on DeepSeek were young people fresh out of college and they looked at things with a fresh perspective. They undoubtedly experimented many times and failed but by thinking out of the box, they came up with something that was faster, better and far cheaper that what had come before them.

Likewise, healthcare system planners should be bold and not think of doing more of the same, because seeking out and getting incremental change is just not good enough anymore.

Famous Doctors (But Not For Medicine)

And just like that, not only are we in 2025, but the Year of the Snake has slithered into our lives as well. Life is stressful as it is and this hobbit has decided that we will start off the year with some light-hearted stuff – about multi-talented doctors who are famous for stuff other than the practice of medicine. Here is a sample of such famous (or depending on perspective, infamous) medically trained people

Sir Roger Bannister (1929 ~ 2018)

The first man to run the mile in less than 4 minutes on 4 May 1954. He was also a revered neurologist in his later years and was Master of Pembroke College, Oxford. He did much research on the autonomic nervous system. He also published a very well received neurology textbook, Brain and Bannister’s Clinical Neurology.

He said he would rather be remembered for his work as a neurologist than for his running. But alas, the reverse is true.  

Michael Crichton (1942 ~ 2008)

He is best known for writing Jurassic Park. In real life, he graduated from Harvard Medical School with an MD, although he never practised medicine. He was also the creator of the long-running and popular TV series ER. His books have sold 200 million copies worldwide.

Sir Arthur Conan Doyle (1859 ~ 1930)

The author of Sherlock Holmes really needs no introduction. He was a graduate of the University of Edinburgh and had wanted to be an ophthalmologist. He started off as a ship doctor before setting up practices in Plymouth, Portsmouth and Southsea, all of which were not particularly successful. But he struck gold when he created the character Sherlock Holmes.

The rights to his first Sherlock Holmes novel (A Study in Scarlet) were sold in 1886 for only 25 pounds. But the character became so popular that it literally refused to die. Conan Doyle had Sherlock Holmes killed in the 1893 novel “The Final Problem” so that he could concentrate on writing other genres. But there was such a public outcry that he had to resurrect the character in the famous “The Hound of the Baskervilles” in 1901

Tun Mahathir Mohamed (1925 ~ )

And of course we have Dr Mahathir, the longest serving Malaysia Prime Minister (a total of 24 years over two spells) and the world’s oldest (at 93). An alumnus of our local King Edward VII College of Medicine (the precursor of NUS YYLSOM), he graduated in 1953 with a LMS (Licentiate in Medicine and Surgery, the precursor to our MBBS) qualification.

As a student in Singapore, he was once driven to the servant quarters of the KEVII Hall instead of the medical student hostel wing because the Chinese taxi driver could not believe that a Malay could be a medical student. And that probably explains why he liked to make things difficult for Singapore from time to time when he was in charge. In any case, in the 2022 Malaysia General Elections, he lost his seat and election deposit as well, which probably reflects how far he has fallen from his once lofty perch.

Ernesto “Che” Guevara (1928 ~ 1967)

A Marxist revolutionary of almost mythical proportions who played a pivotal role in the Cuban Revolution. He was once labelled as “Castro’s Brain” by Time magazine. He was born in Argentina to an upper-class family. As a medical student, he travelled widely across South America and witnessed the widespread poverty and suffering. He concluded that this was the result of capitalist exploitation by America.

He died at the age of 39 when he was captured and killed in Bolivia while trying to start a guerilla insurgency there to overthrow the local government.

Anton Chekhov (1860 ~ 1904)

The great Russian short story-writer and playwright whose body of works has had great influence on other writers and playwrights in the last century. It is said his plays have been made into so many movies that he is second only to Shakespeare. He wrote seven full-length plays, one novel and hundreds of short stories.

He famously said, “Medicine is my lawful wife and literature is my mistress”. He died at the age of 44 after a long fight with tuberculosis.

Albert Schweitzer (1875 ~ 1965)

Doctor, Theologian, Missionary and Nobel Laureate (Peace Prize). His life is the stuff of legends. He has been described as a polymath. He spent his youth studying theology and only entered the University of Strasbourg to study medicine at the age of 30, in 1905, after had been made the principal of the Theological College of Saint Thomas in 1903. He was also an authority in the repair and restoration of old pipe organs that were usually found in churches.

But he is perhaps best known for his missionary work in Gabon and his philosophy of the “Reverence of life” for which he was given the Nobel Peace Prize in 1952.

It is worth remembering what he said on this, “Standing, as all living beings are, before this dilemma of the will to live, a person is constantly forced to preserve his own life and life in general only at the cost of other life. If he has been touched by the ethic of reverence for life, he injures and destroys life only under a necessity he cannot avoid, and never from thoughtlessness”.

Sun Yat-Sen (1866 – 1925)

The man who overthrew the Qing Dynasty and more than two millennia of imperial dynastic rule in China can arguably be said to be the one doctor who has changed more lives than any other medically trained person. He is so revered that they even named the town or city  he was born in after him: Zhongshan, which is adjacent to Macau. In China, cities are never named after a person, not even after founders of dynasties. He is venerated in both Mainland China and Taiwan.

He was one of the two students out of 12 to graduate from the Hong Kong College of Medicine for Chinese (What is now known as HK University) and was licensed to practise medicine in 1892. Before studying in Hong Kong, he actually spent a few years in Hawaii with his elder brother, where he picked up English from attending school there.

He fomented many unsuccessful uprisings before finally succeeding in 1911 with the Wuchang Uprising, using money raised from Penang Chinese. The two or three uprisings prior to the Wuchang uprising were financed by Singapore money, but they were unfortunately unsuccessful. So ever since then, Penang has had the bragging rights to claim that Qing Dynasty was finally overthrown by money from the Chinese community in Penang (and not Singapore, sigh).

Lo Ta-Yu (1954 ~ )

He is sometimes called the godfather of pop music in Taiwan. He hails from a family of doctors and became a doctor to comply with his family’s ambitions for him, graduating from the medical school in Taichung. He wrote the Chinese equivalent of “We Are The World” – “Tomorrow Will Be Better” which was performed by more than 60 artistes from HK, Malaysia, Taiwan and Singapore in 1985. His hits are too many to list here but it is fair to say that anyone who knows Mandarin and who are above 40 years old would have heard and hummed one of his songs sometime in their lives.

Michelle Bachelet (1951 ~ )

Descended from winemakers from Chassagne Montrachet, Burgundy, she ran Chile for 8 years over two spells (2006 to 2010 and 2014 to 2018). Her father was a Brigadier General in the Chilean Airforce and was purged and tortured for opposing a coup led by Augusto Pinochet and she had to flee Chile after his death and live in exile in Australia and East Germany for a few years. Her first spell as President was a very popular one with her achieving approval ratings of a record 84% when she left office (Chilean Presidents are not allowed to serve two consecutive terms). However, her second term was not as successful and she left office with approval ratings of only 39% in 2018. She obtained her medical qualification from the University of Chile in 1983.

Bashar al-Assad (1965 ~),

Bottom of the list is Dr Assad who ruled Syria for 24 years from 2000-2024, after his father died. He was a graduate of Damascus University and was training to be an ophthalmologist in London before being recalled by his father back to Syria after his elder brother died.

Between 2011 and 2024, it is estimated that some 500,000 to 600,000 people died in the Syrian Civil War before he was toppled from power by a revolution led by a coalition of Syrian rebels. He ran a totalitarian regime and was not averse to using chemical warfare on his opponents during the civil war. He has fled Syria last year and now lives in exile in Russia. Maybe he should have stuck to his ophthalmology training in London.

Income’s Outcome Is Likely To Be Worrisome

A Brief History of Medical Indemnity Cover in Singapore

Younger doctors may not know this. There was a time when all doctors in Singapore had to buy their own professional medical indemnity plans. MOH or MOHH did not arrange for coverage for public sector doctors. Whether you were a medical officer or private sector specialist, you bought your plans through SMA, who acted as the agent for these providers.

Prior to 1999, there were two providers: MPS (Medical Protection Society) and MDU (Medical Defense Union). There both originated from the UK. They actually were not licensed by the local regulatory authority (i.e. Monetary Authority of Singapore, MAS) to sell policies locally. These medical indemnity plans or policies were issued directly out of UK and SMA was paid some fees in the process for the administrative work done.

MPS still exists today and the arrangement between SMA and MPS is still largely in place. However, in 1999, MDU decided to pull of Singapore for reasons best known to themselves. They had struck an agreement with MPS whereby MPS will continue to offer coverage to ex-MDU customers for a fee. In an article written by Past SMA President Goh Lee Gan in the September issue of SMA News in 2002 titled, “The Inside Story of UMP Singapore”, he said he received the news of MDU’s pulling out and handing over of their business to MDU on the rather auspicious date of 9 September 1999 or 9/9/99.

The SMA leadership then decided that it was imprudent to have only one provider for medical indemnity services in Singapore (and a foreign-based one at that) and decided to introduce another provider. This came in the form of the largest medical indemnity provider in Australia at that time – UMP.

However, UMP’s presence in Singapore was very short-lived because back home in Australia, quite a few court judgments went against doctors (especially in its home state of New South Wales [NSW]) and these cases came with huge damages awarded. UMP was declared insolvent and went into provisional liquidation. It was subsequent revivedly with government funds to the tune of A$260M accompanied by tort reform. But the end result was that UMP could only operate in Australia and UMP’s presence in Singapore lasted only 2 years. It has to be said in that short period, there was no evidence that UMP’s business in Singapore was unviable.  

Once again, the Singapore medical profession faced the prospect of having only one foreign-based professional medical indemnity provider. This time, SMA approached NTUC Income. In the aforesaid SMA News article, it was reported, “A/Prof Goh spearheaded the venture with NTUC Income, and held discussions with Mr Tan Kin Lian, CEO of NTUC Income, about providing medical indemnity cover for doctors”.

And so, since 2002, NTUC Income (or should I say, Income, since the prefix of “NTUC” was regrettably dropped in 2022 when NTUC Income was corporatised) has been a medical indemnity provider in Singapore.

The market share of Income in providing medical indemnity cover is probably very small and the profits attributable to this business line, if any, are probably insignificant to Income. Many doctors may not even realise it is a provider, but it’s there: (https://www.income.com.sg/commercial-insurance/medical-indemnity-insurance)

The negotiations between Prof Goh and Mr Tan obviously went well because in 2002, NTUC Income stepped into the breach to ensure that medical profession was not subject to the crutches of a potential monopoly situation. The impact of this strategic move should not be taken lightly, because should the remaining, foreign-based provider also pull out, or raise its premiums to very unaffordable rates, then healthcare provision in Singapore will be at peril. This was the situation NSW faced in 2002 when UMP folded which left thousands of doctors without cover. The NSW government of the day had to use public funds to bail UMP out, so that doctors could continue to be covered and healthcare could continue to be delivered.

In short, NTUC Income did “national service” in 2002 and continues to do so even today.

The Deal

In this historical light, this Hobbit, like many others, received the news that Allianz was buying 51% of Income Insurance for $2.2B with much discomfiture, if not apprehension.

Since then, the Chairman of NTUC Enterprise, Mr Lim Boon Heng has come up with several reassurances that things will be alright. These include “NTUC Enterprise will continue as an active shareholder of Income Insurance to keep it to its purpose and deliver social commitments to its policyholders” (24 July, “Income will still provide affordable insurance for lower-income customers after Allianz deal: NTUC Enterprise chairman”, CNA).

However, not all are convinced and the logic is simple. A 51% stake is a majority or controlling stake. It is no coincidence that Allianz wants 51% and not 49%. It intends to control the way the acquired entity is run. Unless there is some written contractual term in the acquisition document that enables the minority shareholder to influence or demand that the majority shareholder behaves or acts in a certain way, the majority shareholder will call the shots. These contractual terms are commonly called “reserved matters” in which e.g. despite Allianz having a 51% share of the company, minority shareholder NTUC Enterprise can compel Allianz to manage Income Insurance in such a way that Income Insurance will continue to “deliver social commitments” and “still provide affordable insurance for lower-income customers” beyond the $100M committed for 10 years from 2021 (as stated in the Clarification issued on 25 July 24)? We are already in the second-half of 2024….

The Clarification on 25 July also states that Income Insurance will “provide access to insurance for seniors, people with mental health concerns and those with special needs, such as Down Syndrome and autism”. That sounds good. But it remains to be seen at what price such coverage will be given and if there are any strings attached. The devil is in the details, as the saying goes.

Anyway, if there are such reserved matter clauses in the agreement, let’s see it. If not, this hobbit will take such reassurances with a large pinch of low-sodium chloride (Healthier SG and our Health Minister promotes the use of low-sodium salt, so this hobbit has to follow too).

In any case, this hobbit speculates that should this deal go through, it is unlikely that Allianz-controlled Income Insurance will continue to provide medical indemnity services. I don’t think German-origin Allianz is in the business of doing national service in Singapore, unlike NTUC Income, which has its (although now probably severely-mutated) DNA in Singapore’s labour movement. In any case, Medical Indemnity is not mentioned in the aforesaid Clarification.

Nonetheless, this hobbit declares that he does not obtain medical indemnity cover from Income and so, even if it does cease to cover such services, he will not be adversely affected in the short term.

Me and My Incomeshield

On a personal note, this hobbit is more concerned with his Integrated Shield Plan (IPs), which he had bought from NTUC Income years ago and continues to pay the premiums. This hobbit is probably not alone in the situation he has found himself to be in.

Let’s do another recap of the history of Medishield and IPs. In 1990, Medishield was introduced to cover B2 and C class inpatient bills. In 1994, IPs were introduced. Actually, this hobbit isn’t sure if the term “IP” existed then. But in any case, insurance products providing cover for restructured hospitals’ B1 and A class services were introduced. This happened at about the same time when the government took away inpatient healthcare benefits from civil servants. This was in the Jurassic age when all NUS medical graduates were bonded and employed directly by MOH itself as civil servants (except for a small group of graduates who were directly employed by NUH to serve out their bond).

After our inpatient medical benefits were removed (in return for 1% more CPF employer contribution), many of us bought Income’s Incomeshield products. If my memory doesn’t fail me, there were only two products: Incomeshield A and Incomeshield B. The former covered A class charges while the latter covered B1. An IP product to cover private hospital charges had not been yet created then.

It is important to note that NTUC Income virtually enjoyed a monopoly in this product segment from 1994 to 2000. This hobbit, like many of his contemporaries, did not have a choice between providers. It was either buying NTUC Income’s Incomeshield or self-funding for inpatient services.

It was only sometime between 2000 to 2002, that two other providers were introduced to provide IP or IP-like products: AIA and Great Eastern.

In other words, it is not unreasonable to think that there are now large numbers of people who had bought Incomeshield A and B in those years where NTUC Income was the only provider of IP products and now continue to be their policyholders. They are probably now in their fifties and sixties. If they had not switched out of Income when they were younger, they are probably stuck with Income now, because by now, many of them would have developed medical problems and no other IP insurer will take them as policyholders because of their pre-existing disease(s).

And so, just as you are about to more likely claim from Incomeshield plans when you are now in your fifties and sixties, you are now also faced with the prospect and uncertainly of Income being controlled by a for-profit foreign insurer whose loyalty, and indeed fiduciary duty, is to its shareholders. Post-acquisition, will my Incomeshield premiums still be affordable? Or will they go up significantly, because the majority shareholder needs to recover its $2.2B investment and also to profit-maximise?

It also doesn’t help that Allianz’s record is not entirely spotless. (https://www.reuters.com/business/finance/allianz-pay-6-bln-over-structured-alpha-fraud-fund-manager-charged-2022-05-17/)

In this hobbit’s opinion, in all likelihood, this Income deal will prove to be a bad outcome for many Singaporeans, but a good deal for the investment bankers, management consultants and lawyers paid to see the deal through.

Eyeing the Problem

There has been some concern over a spate for ophthalmologist resignations from the public sector in the last 12 months or so.

But first, some statistics to put things in context. In the latest SMC Annual Report (2022), it was recorded that there are 314 ophthalmologists in Singapore, of which 122 worked in the private sector and the rest (192) worked in the clusters. Therefore, about 39% of all ophthalmologists are from the private sector.

From 2018 to 2022, a period of 4 years, the number of ophthalmologists increased by 42, from 272 to 314. That’s about an increase of 10.5 per year in this period. I.e. we are increasing the number of ophthalmologists by about 10 a year, nett of the ophthalmologists who retire in the same year.

If we assume that the country produces nett 10 ophthalmologists a year, and to maintain the market share between private sector and public sector at around the current 40%/60% split, then roughly 4 ophthalmologists should leave in a 12-month period for the private sector.

However, In the last 12 months, a total of 15 ophthalmologists have left the public sector or have tendered their resignations and are now serving notice, give or take a few. And interestingly, the vast majority of these 15 are senior consultants, or on the verge of becoming one, since the most junior ophthalmologist of these 15 was already registered with the SAB (Specialist Accreditation Board) in 2016, i.e. with at least 7 years of experience as a specialist before resigning. Three of them are very senior, having graduated in the 90s and collectively have chalked up some 60 years of specialist experience between them.

To better understand why so many ophthalmologists have left or are leaving in the last 12 months, we need to first acknowledge that there are several peculiarities of ophthalmology:

  1. The practice of ophthalmology is not as dependent on hospitals as many other disciplines, not unlike dermatology. Hence there is a less pressing need for one’s practice to be located in a clinic suite that is co-located with a private hospital. Hence, an ophthalmologist doesn’t have to pay sky-high rents.
  • Secondly the epidemiological trends of eye diseases are firmly on the ophthalmologist’s side. At least 80% of Singaporeans become myopic by the time they reach adulthood, and this translates into a great pool of patients that can benefit from refractive surgical procedures e.g. Lasik. 80% of the elderly will develop cataracts, which again serves as a very large source of patients.
  • Due to the perceived criticality of sight, patients in this day and age do not wish to be treated by family doctors for eye conditions except for the least complex of conditions that can be treated with just eyedrops and ointments prescribed by the family doctor. Gone are the days when a family physician will routinely attempt to lance a stye or excise a chalazion. Some still do, of course, but they are few and far in between, especially among the younger family physicians. Most GPs are not trained to perform indirect ophthalmoscopy or tonometry and do not have the equipment anyway. All this means that, in comparison to most other disciplines, ophthalmologists take up an inordinately large share of the disease burden.

A secondary factor that needs to be discussed is the role of insurance in private sector ophthalmology. While many other specialties are very dependent on insurance-funded work, ophthalmology is less so. This is because non-insurance work are a plenty in ophthalmology in the form of Lasik procedures and even aesthetic blepharoplasty. That is why despite insurance players resisting recruiting new doctors onto panels and cutting down on reimbursement rates, ophthalmologists have no problem earning a decent living in the private sector sans insurance.

The above can be considered as unmodifiable factors that are particular of ophthalmology that makes going into private practice less daunting when compared to other disciplines.

But it doesn’t quite explain why the sudden exodus has happened. Your friendly neighbourhood hobbit actually went to talk to a few of them. When folks in their fifties and late forties leave, you can be sure that there are significant push factors behind the move. This is in contrast to someone leaving for private practice when they are in their thirties and early forties, when pull factors play a more important role in the decision-making process.

Some of the push factors expressed include:

  1. A relentlessly and sharply increasing workload and punishing work schedule that gets harder and harder to keep up with as one gets older. As one ophthalmologist put it, “At the rate this is going, I can’t see myself growing old and retiring in Institution X, because I don’t think I can keep working at this rate. Might as well go out and work at a less punishing pace now and lengthen my working life”.
  • Changing of remuneration policies. Each institution has a different work and pay culture. Some are more ‘capitalist’ and some are more ‘socialist’. Not a few said that a particular institution was getting more and more socialist in remuneration policy and yet workload kept increasing. Another ophthalmologist said, “You cannot have your cake and eat it too. If you want to make me work harder and see more patients, then pay me more. The pay structure has to incentivise me to chase after more patients. Communist countries failed economically because socialist-style remuneration did not lead to more productivity”. (Oops. This one really hit home for me)
  • There is a need to strike a better balance between research, teaching and clinical service. “Some of us are bearing the brunt of the massive workload and bringing home the bacon for the institution but we are getting paid less than folks who see fewer patients and spend most of their time doing research”.  This is nothing new, the tension between service needs and academic medicine. But somehow the already-delicate equilibrium between the two has apparently deteriorated lately, probably brought on by the rapidly increasing service workload. The tension is more manageable when the workload is likewise manageable. But when the workload becomes unreasonable, then old wounds concealed by a thin scab may just dehisce again.

The obvious solution of course is to train more ophthalmologists to meet the demands of workload. But it takes a long time to train an ophthalmologist. So, in the meantime, the fastest way to beef up supply in the public sector is to recruit ophthalmologists from overseas. Singapore public sector pays relatively well compared to some other countries and it would not be too difficult to recruit ophthalmologists from e.g. UK. But in the long run, this may not solve the problem either. There have been examples of foreign-trained specialists who likewise leave for private practice once they obtain full SMC registration. For foreign-trained specialists with a basic medical degree that is registrable with SMC, the time taken to convert from conditional to full SMC registration can be as short as 2 to 3 years. Unless we plug this hole and mandate a longer period of service before a foreign-trained specialist can obtain full registration and can therefore leave for private practice, recruiting more foreign-trained specialists may be a just a short-sighted or stop-gap measure at best.

In addition to addressing directly some of the push factors stated above, perhaps a better approach is to better distribute the workload between the private and public sector ophthalmologists. But this would require the cooperation of insurers, especially the Integrated Shield Plan (IP) insurers. Not just particular to ophthalmology, IP insurers have  instituted a suite of measures to restrict and reduce IP work in the private sector while pushing more and more work back to the public sector, thereby exacerbating the demand-supply imbalance there. These measures include not just disincentives to seek care in the private sector even though the IP policy provides adequate private sector coverage, but also incentives for the policyholder to go back to the public sector.

There are no easy solutions here but obviously something needs to be done quickly to turn the tide. If not, the dark triumvirate of poor morale, worsening working conditions and more resignations may spill over to the public domain in the form of ballooning waiting times for appointments and surgeries.

Do We Have Too Many or Too Few Doctors?

A New Year brings new hopes and aspirations. And new worries and fears, unfortunately. In this new year, the hobbit wants to wish all readers of this nonsensical column a very ungratifying year and may all of you remain as ingrates.

This is because in 2024, the scariest word is gratification. Woe be unto you should any of you (especially those in the public sector) be suspected to have received gratification. Gratification can be displayed in many different forms; these include free concert and F1 tickets, or may even be just letting off a loud burp or two after a heavy meal or an upsized cup of bubble tea.

So remember, in 2024, stay ingrate.

Having dispensed with this New Year Greetings and leaving all ungratified, let us now set our eyes on this post’s question: Do we have too many or too few doctors?

As the cliché answer goes – it depends on who you ask

If you ask the public sector folks – they will say too few. The public healthcare clusters are desperately trying to recruit new doctors to fill vacancies that are created when new hospitals and polyclinics are launched. And the government are building these public health institutions (PHIs) rather quickly, in anticipation of increased healthcare needs of an aged population. The frequent complaints about waiting times and appointment times at polyclinics and specialist outpatient clinics reinforce the view that we don’t have enough doctors in the public sector, at least.

But if you look at the MOH Singapore statistics, in 2022, we have 2.8 doctors per 1000 population or about 1 doctor to 357 persons. This figure is in line with those of many developed Anglophone countries, including USA, Canada, UK, Australia etc and better than most countries in the region, including Korea and Japan. Also, Singapore is a small city-state that does not suffer from difficulty of having physical access to doctors that sparsely populated large countries may experience. In other words, even we may not have too many, we probably have enough or near enough doctors, going by national and international statistics and norms.

Then again, if you ask doctors in private practice, they will say the situation is rather saturated and we have enough or even too many doctors. Apparently, seven ENT surgeons have left or are leaving for the private sector in 2024. And we are in January. Prices and rentals for specialist clinic space in private hospitals are shooting up again, suggesting that demand far outstrips supply.

The Public Sector

But let us go back to the public sector again since the public sector employs the majority of doctors. In the latest SMC Annual Report (2022), it is stated that there are a total of 16,633 doctor in Singapore, of which 10,938 worked in the public sector and the remaining 5,695 working in the private sector. (i.e. 65.8% working in public sector or about two-thirds)

Of the 10,938 doctors in the public sector, 4,536 were specialists while 6,402 were non-specialists.

According to a recent article in the Straits Times, (9 Dec 2023), there were 624 doctors working in our polyclinics. These are in all probability not specialists registered with the Specialist Accreditation Board (SAB). That leaves about 5778 non-specialists working in the public sector less polyclinics. There were also 624 house officers in 2022 who need close supervision.

There are a relatively small number of public sector doctors who work in MOH, the statutory boards such as HSA, HPB, and agencies such as MOHH, AIC, Synapxe etc. If we ignore this small group, and take away the 642 polyclinic doctors and 624 house officers, there are 9690 doctors in the public sector. Of which the 4536 specialists would make up 46.8% of all doctors in the public sector.

In other words, there are almost as many specialists as there are medical officers working in the clusters’ hospitals and national specialty centres.

Obviously, this was not the case in our restructured centres long ago. Older doctors can all testify that specialists were a rare thing. In fact, even registrars were a rare thing. Once you pass your M.Med, you are either a Registrar or a MOS (Medical Officer Specialist), and you are given that prized object – the black name tag, which you proudly wear (if you are male) on top of your shirt pocket. You are now officially known as a “Tua Lo Kun” (Big Doctor in Hokkien) and you can now strut down the ward corridor with a spring in your step. Even senior nurses like ward sisters (aka ward managers) treat you with deference. You also get a respectable night call allowance (i.e. more than forty bucks). You gladly buy your on-call team supper. Actually, the registrar paying for supper was almost an obligatory thing, mainly because the more junior doctors were paid peanuts or nothing.

When you become a consultant, you have reached minor warlord status with your small team of registrar, medical and house officers. A consultant cannot be left alone when he or she visits the ward to see patients. A nurse and a house or medical officer will rush to the consultant’s side when he reviews his patients, to take instructions and to update the case-notes.

And finally, when one reaches the demi-god status of senior consultant, junior staff who are not in your team actually now avoid you or at least your stare while those who are, fawn over you, or least pretend to. The air thickens around you wherever you go, and now you are accompanied by the ward sister and at least a registrar when you review your patients. The ward doctors and staff hold a mini-conference before they make the decision to page you, or not. (For young readers, please be informed that there was this thing called a pager and “page” is both a verb and a noun).

Well, all that has changed with the above distribution of medical manpower currently in our restructured hospitals and national centres. As the numbers show, almost half the doctors are specialists. And this hobbit has been told that about half of the specialists are senior consultants (this hobbit has not been able to verify this claim). In other words, if this is true, then about 1 in 4 doctors are senior consultants, another 1 in 4 are either consultants and associate consultants.

There are no more entourages for senior consultants, except maybe the head of department or previous heads of departments. There just aren’t enough junior doctors to accompany every specialist that comes around in the wards. In some departments, the senior consultants outnumber the house officers.

It is therefore a “top-heavy” distribution of medical manpower. Obviously, we have to work in new ways now. But in the long run, one must ask, is this distribution of medical manpower sustainable from a cost-effectiveness point of view? Yet, at the same time, as aforesaid, we often hear of a large number of public sector specialists resigning for the private sector. One wonders, are they mainly senior consultants or more junior specialists?

It is a very complex situation but it would be nice to know what are the planning norms for medical manpower in our public healthcare clusters? E.g. what percentage of doctors should be specialists? And of these, what is the desired proportion for Associate Consultants, Consultants and Senior Consultants? Of course the tertiary hospitals  and national centres could have a larger percentage of senior consultants etc.

This hobbit doesn’t know how many doctors and specialists the public sector needs as a whole, but the gut feel is that we probably either have too many senior consultants, too few junior doctors, or both.

The specialist manpower planning in our clusters is also inextricably linked with the private sector and national situation. It has been said that specialists should comprise 40% of all doctors in Singapore. This target has already attained currently with 40.3% of all doctors being specialists.

The Private Sector

This figure would include the significant number working in the private sector and especially the private hospitals. In our private hospitals, almost all doctors are specialists. But a closer look at the private sector would reveal that only about 38% of doctors in the private sector are specialists, (2163 are specialists out of 5695 private sector doctors). One would assume (wrongly) that the bulk of the remaining non-specialists would presumably be family physicians (FPs).

There are 3532 non-specialists working in the private sector of which only 1707 are registered FPs. That leaves 1805 non-specialist doctors in the private sector who are not on the family physician register. One wonders what do they do? Locums? Working in pharmaceutical companies? Resident MOs in private hospitals? Aesthetic GPs? This hobbit confesses he doesn’t know how this diverse group of doctors can come up to 1805, outnumbering the number of FPs.

Ideally, this group of “undifferentiated” non-specialist doctor in the private sector should be deployed where they are needed most. Perhaps more can be retrained as FPs through the GDFM (Graduate Diploma Family Medicine) route?

Let’s return to the specialist manpower situation again. The recent announcement by MOH (8 Jan 24) that it is interested in exploring the idea of setting up a not-for-profit private acute hospital should be supported. Another Mount Alvernia-like hospital would allow for more specialists to go into private practice without incurring the costs associated with the astronomical price for for-profit private hospital land in Singapore.

Perhaps this not-for-profit private acute hospital would address the possibility that we are having relatively too many specialists and especially senior specialists in the public sector.

But for this to happen, there needs to be a national and professional-wide consensus on the following:

  1. Do we have enough doctors nationally? (with a doctor-patient ratio of 1:357)
  2. Are we getting enough doctors every year (both locally and from overseas, ~ 600 to 700)?
  3. Are we training enough of these doctors to be specialists? (~40%)
  4. Do we have enough specialists nationally, now and going forward (in terms of percentage and in absolute numbers)?
  5. Do we have enough specialists in the public sector (in terms of percentage and in absolute numbers) compared to junior doctors?
  6. Do we have enough senior consultants in the public sector (in terms of percentage and in absolute numbers)?

In line with this New Year’s theme of avoiding any form of gratification, this post ends with more questions than answers……

Not So Merry A Season

It’s that time of the year when practically everyone you know is on holiday overseas. They are taking full advantage of the almost almighty Singapore dollar and standing up for Singapore by chirping “cheap, cheap” from Tokyo to Tasmania and from Seoul to Sao Paulo. Of course, most people do not realise that there are zero-sum games in this world after all – if we find everywhere else cheap, then everyone else also probably finds us expensive. Which probably explains why Orchard Road is rather quiet nowadays, when compared to other shopping districts in the major cities of Asia. But it’s OK, in the meantime, just enjoy the almost almighty Singapore dollar and almost all-conquering Singapore passport.

It’s the season to be merry, after all. But not for quite a few folks

The first group of folks would be the board of directors, management, shareholders and customers of Cordlife Group Limited. In a shocking revelation, several storage tanks in its Singapore operations for stem cells were found to have been exposed to temperatures exceeding that which is deemed allowable. This calls into question if the cells and tissues stored therein are still viable should they be needed. In any case, an accreditation body called FACT (Foundation for the Accreditation of Cell Therapies) has suspended their accreditation of the bank. Most if not all reputable hospitals who can perform stem cell transplants will only take samples that have been stored in cord blood banks that are accredited with internationally reputable accreditation agencies – FACT is one of them. In other words, even if the cells stored are viable, they may not be deemed usable because the accreditation status is now suspended.

Anyway, the incident calls into question a few things, including

  • When and how much did the management and board know about the shortcomings?
  • What was done to uncover the full extent of these incidents to get a full picture of the number of incidents in tank(s) were exposed to higher than allowed temperatures?
  • What were the reasons for these failures in operations, escalation and disclosure?

This will entail probably the Mother of all RCAs (Root Cause Analysis)…..And we haven’t even talked about how this incident affects Singapore’s reputation as a healthcare hub.

The next unmerry thing on the radar is the alleged corruption of the AON Singapore CEO, who has been accused of taking a bribe amounting to $240,000 from Fullerton Healthcare. At first glance, two things are interesting about this case. First, this hobbit doesn’t know how much an insurance broker like AON pays their Singapore CEO, but it is probably well in excess of $240,000 a year. The fact that he was willing to risk his entire well-paid job and possibly end up as a criminal for $240,000 defies common sense. Also no present or past employee or director of Fullerton Healthcare has been charged yet by CPIB. Watch this space carefully.

We move onto something else pretty interesting developing in the Third Party Administrator (TPA) Scene. An unnamed TPA was said to have offered new fee scales to its panel of ophthalmologists. These new scales are so low that they fall well below that of the MOH Fee Benchmarks. In fact, an older ophthalmologist was said to have remarked that the new fee scales are even below what he was offered more than 10 years ago by the same company. Apparently, in 2011 a Table 4A operation was reimbursed at ~$2800. In 2024, the same Table 4A was to be paid ~$2200.

This hobbit is also hoping his bowl of Bak Chor Mee in 2024 will be cheaper than what he paid for in 2011, but that is wishful thinking bordering on the mythical, like Santa coming down the chimney bearing gifts.

But myths and wishful thinking will remain just what they are. Reality, on the other hand, bites. Apparently, more than 90% of the original ophthalmologists who were on this TPA’s panel came to their independent and individual conclusions that it was unwise to remain on this panel for reasons best known only to them and they then quit one by one; leaving just a handful left on the panel. It’s a free world and a market economy we live in. Payers have a right to offer fee scales as they see fit and service providers have a right to independently reject them for whatever reasons. But if I were this TPA’s clients, I would ask why did my panel of ophthalmologists shrink by more than half in 2024 when compared to 2023?

Finally, its squeaky-bum time for the Integrated Shield Plan (IP) providers. On 9 Dec 23, Mr Han Fook Kwang wrote in ChannelnewsAsia (CNA) this commentary titled, “Amid ever-raising premiums, let’s make for no-claim individuals to switch private health insurers”. Now Mr Han is the Michael Owen-equivalent of Singapore journalism. He was the Editor of The Straits Times for many years but now writes for CNA, not unlike how Michael Owen played for Liverpool before playing for Manchester United, both periods to wide acclaim.

In this commentary, Mr Han has come to the conclusion that:

  1. The IP providers want to collect premiums when you are young but are happy for you not to be covered by them when you are old (i.e. the concept of cherry-picking or adverse selection)
  2. There is no real competition between IP providers once a person has chosen to stay with one IP provider due to pre-existing diseases
  3. Smaller IP providers charge higher premiums and also make financial losses

He then recommends:

  1. (More) government supervision and action
  2. Beyond ensuring the financial viability of insurers, there should be someone (or some government agency) out there to look after the interests of the customers
  3. There should be “closer oversight of the premiums charged and what they cover”.
  4. Allowing for “portability for those who have not made any claims for a certain number of years”.
  5. So as to facilitate “a gradual migration to more efficient companies charging lower premiums”
  6. Three to four IP providers will suffice for a relatively small market like Singapore so that real competition exists, instead of seven providers

Many of the above points have also been covered by this Hobbit previously in this Blog over many posts but of course nobody pays attention to mythical me. Hopefully the guys in MAS, the stated regulators of insurers, will pay more attention to what Mr Han is saying. Even though going by the past record of MAS, this is most likely going to remain a hope and nothing more. But’s it is Christmas and Christmas is the season of hope. The hope that MAS will do more than pay attention to financial viability or health of insurers, but also do what Mr Han said about looking after “the interests of customers”.

Finally, we move on to the ongoing Public Consultation of the Health Information Bill (HIB). It’s interesting how this Consultation is carried out – which is in the form of a survey or a questionnaire. The survey consists of a number of questions that demands the respondent to answer in a binary-outcome fashion, either a “yes” or a “no”. Each question is followed by an optional free-text box for you to elaborate, should you so wish.

I think whoever designed this survey should be sent either to the Civil Service College or the Saw Swee Hock School of Public Health for a short course in survey or questionnaire design, because enforcing a binary outcome does not lend itself well to understanding and analysing the nuances in attitudes of diverse stakeholders in what is now usually a complex policy environment. Many respondents may not use the free-text box provided and even if they do, the free text cannot supersede the “yes” or “no” response.

You are conducting a consultation to receive feedback so as to draft bills and fine-tune policies. You are not conducting a referendum like in the Scottish Referendum of 2014, when the Scots were asked whether they wanted to be an independent country or not, in which case a “yes” or a “no” answer is fit for purpose.

Indeed, a “yes” or “no” answer makes for easy analysis later when the consultation process is over. But what will be the quality of the analysis of the survey outcomes that can possibly come out of such a blunt approach?