Recently I received in my email an EDM about a seminar organised by the SMA, “Taking the Plunge – Going Into Private Practice” which will be held on 26 Aug 2023. That set me on thinking of what it means to go into private practice in the post-Covid world of 2023.

Specialists

I was just chatting with some young surgeons the other day and was astonished to find out that apparently, at least 12 orthopaedic surgeons have left for the private sector in the first six months of 2023! From anecdotal evidence, this exodus is not just limited to orthopaedics but extends to other specialties as well.

There are several interesting new trends in the current round of private sector entrants in the specialist sector. For one, very senior people, including folks in their fifties are leaving when in the past, it was those in their late thirties and early forties who usually quit. You hardly if ever hear of a fifty-something year-old leaving. Secondly, folks now don’t leave one at a time from one department. They often leave in twos and threes.

This sudden surge in folks leaving for private can be another unwanted aftermath of the Covid-19 Pandemic. Few people dared to leave for private in the Covid years of 2020 to 2022, and so now there is a rebound, as in the number of people who normally would have left for private over three years have now been compressed into a one-year period.

Of course, when folks go private, they have to go somewhere in private. And this somewhere has translated into sky-high prices and rentals in popular private hospitals. Clinic space in a big freehold-lease private hospital have reached $12,000 to $13,000 per square foot. In another large hospital in town where only about 60 years remain of its 99-year lease, prices are going at about $9000 per square foot. Rentals in both these hospitals are now frequently in the $23 to $25 per square foot range.

All this may suggest that the environment is hunky-dory outside in the private sector but this cannot be further from the truth. Firstly, severe manpower constraints, especially in nursing, have meant that private hospitals often cannot be operating at full capacity. Wards and especially operating theatres are not infrequently closed. Unless absolutely urgent or it is an emergency, one frequently cannot find a bed to admit a patient. OT slots are even harder to find and many surgeons have told this hobbit that they consider themselves very lucky if they can find an elective OT slot within three weeks for their patients. So there are some serious capacity issues that limits one’s earnings in the private sector, even though demand for their services may remain high from both local patients with integrated shield plans (IPs) and overseas patients.

Which brings us to the next topic of the day, IPs. IP reimbursement remain parsimonious and clustered at the lower half of the MOH Fee Benchmarks. MOH has just released the second edition of the Benchmarks last month. It remains to be seen if the IP providers will revise their reimbursements upwards to keep pace with the newly-revised Benchmarks.

Another perhaps even more discouraging trend we are seeing is that IP providers are seemingly very reluctant to admit new specialists to their preferred panel of providers. The common lament of new private sector specialists we hear is that they find it extremely difficult to get into IP panels. Older and more established doctors may belong to four or five panels but newer ones consider themselves lucky to be in more than one panel.

Therefore, there is possibly a “dual ossification” happening here. The first ossification is that of reimbursement rates as IP providers drag their feet to pay more to be in line with the new benchmarks, resulting in specialists’ earnings per patient or per procedure unlikely to increase significantly anytime soon (if ever). The second ossification is of preferred provider panels where these panels are largely frozen in time with very limited number of new entrants resulting in new specialists being shut out. Frankly, this hobbit thinks that regulators should state some standards for preferred panels. The size of panels should be in line with the number of policyholders an IP provider has. For example, an IP provider with 1M policyholders should have 2x the number of preferred providers that another IP provider with only 500,000 policyholders has. And it should be stated that no matter how small the pool of policyholders are, every IP provider should have at least have  a bare minimum X number of preferred providers.

These two phenomena are actually known to the specialists who are contemplating going private.

If you think about it, a specialist going private now have to face up to a quintuple-whammy of:

1. Reimbursement rates by IPs not increasing fast enough or at all
2. Getting acceptance into an IP preferred provider panel is getting more and more difficult
3. Rapidly rising prices for purchase or rental or clinic space/medical suites
4. Workload constraints due to healthcare facility capacity limits and/or manpower shortage
5. Increased competition among increasing number of private sector specialists

Yet, they are still going private. Why is this so?

This hobbit thinks that this may have to do with expectations:- Things are bad, but if you are convinced that if things are not going to get better, then even if things are bad now, it is still better to leave sooner rather than later.

Will workload and waiting times in restructured hospitals get better? Will the EMR get easier to use? In a mistake-intolerant environment, will the trend to get consultants to do more and more work that were previously done by medical officers and residents reverse itself? Will private hospital clinic space get cheaper when no one knows when will land for a new private hospital be made available?

If the answer to the above questions is a consistent “No”, then people will still leave. In other words, whether the going is good or not is not as important as whether the going is going to get worse; i.e. staying on is not tenable.

A simple example of the importance of expectation is that of private hospital and private hospital clinic or medical suite space. The last private hospital land was released 15 years ago, around 2008. No one knows when the next piece of land will be released for building a private hospital. This is exacerbated by the precedent of sky high prices paid for the last private hospital land that was put up for sale. This leads to the current situation where specialists will pay an arm and an leg to secure medical suite space. The uncertainty of when new hospital co-located medical suites will be made available in the market leads to the persistent expectation that demand will outstrip supply which in turn feeds higher prices for such assets. This can been seen by the fact that 15 years after the last release of private hospital land here, the 2008 price for that piece of land is probably still the most expensive hospital land on this planet (on a per square foot built-up area basis) today!

Things would be different if the relevant authorities are publicly committed to releasing land for say, a 300-bed private hospital every 10 or 12 years. Specialists and hospital operators will then plan accordingly with that certainty in mind, instead of pushing up prices for land and medical suite which in turn leads to more and more expensive private healthcare.

Family Physicians (FPs)

On another note, let’s turn our attention to FPs. Healthier SG has been largely welcomed by the current generation of FPs. But among younger doctors still in the public sector, many are also thinking of going private as well; either to set up their own GP clinics or groups, or to join an existing group. The reasoning is quite simple – Enrolment under Healthier SG is truly underway now. However, in a few years, it is expected that everyone will be enrolled with a FP under Healthier SG. In fact, this is one of the stated aims of Healthier SG – Everyone should have a FP. Will there be many people who still need to be enrolled with a FP in five years’ time? The only folks that may require enrolling in the future may be new PRs and citizens, who did not enjoy Healthier SG benefits when they were  previously not residents in Singapore.

In other words, the Healthier SG pie for new FPs will be getting smaller rapidly as the pool of people without Healthier SG shrinks. It is also likely that future generations of Singaporeans will sign up with the same Healthier SG providers that their parents have enrolled with. Or rather, they may have already been signed up when they were kids, and they will likely continue with the same providers when they grow up. Not unlike why this old coot is still using the same POSB bank account that he has had since Primary 1 when some nice bank officer came and signed up practically everyone in the class.

In business school, they call this “first mover advantage”. Indeed, the first mover will almost always have an advantage. But it cannot be to the point that future generations of FPs will be existentially disadvantaged. Young FPs and FPs- to-be now in the public sector are right to worry about this and policymakers could pay attention to this so as to make Healthier SG attractive for future generations of FPs.

In the 10 years preceding Covid-19, from 2009 to 2019, MOH Budget tripled from S$3.7B to S$11.7B. In FY2022, MOH Budget peaked at 19.29B, understandably so, due to the demands brought on by fighting the Pandemic. In the current FY2023, the MOH Budget has shrunk a bit to S$16.8B, as we gradually leave the Pandemic behind us. S$16.8B is still 44% more than what was budgeted in the year preceding the Pandemic, in FY2019. That’s still a lot of growth. And if we extrapolate back to 2009, the 2023 MOH budget is 4.5 times larger than what it was in 2009, a mere 14 years ago.

In any other country that this hobbit can think of, if the government pumped so much money so quickly into the system, you would imagine that there would be better morale amongst healthcare workers in the public sector, because ultimately an influx of such magnitude so rapidly would lead to better pay or more staff to share the workload, or both.

However, when this hobbit talks to young doctors, the mood cannot be more different. It is not uncommonly a spirit of resignation and defeat. Many are heading for the exits, or at least seriously contemplating so. And this is very worrisome. Because as this Hobbit grows older, he needs more and more medical care and he would like to treated by doctors who are at the very least satisfied with their professional lives.

There are many reasons given for this unhappiness. Many of these reasons have been discussed in detail before – excessive and unsatisfying paperwork and administrative duties, unreasonable patients and family members who may even abuse them, bosses who are overly demanding, an environment intolerant of mistakes and even underperforming hospital IT systems etc.

As this hobbit approaches the autumn if not winter of his medical life, he has the luxury of looking back. If he had to live his life again, would he have chosen to apply for Medicine in the local university when he turned 19 so long ago? The answer is still a “yes”. I cannot say the same thing for folks turning 19 now in 2023, though. And that’s the difference.

Wanting and choosing a career in medicine involved many things that haven’t changed much since then: it is a calling, hard work, long hours, sacrifice, satisfaction, status etc.

Over the years, there is also another constant that medical school admission interviewees don’t mention much, but many want to be doctors because they were in search of a better life. I’ll be honest here, one of the bigger reasons why this hobbit chose medicine as a career was that he believed this career would lead him to a better life. A career in medicine has largely delivered on this count for me.

In itself, there is nothing wrong with wanting a better life. One can even say it is a human right to want a better life, similar to the pursuit of freedom, happiness and human dignity.

But what is a better life? To answer this question, we must first recognise “better” is a word that has connotations of relativity. Better than what or who?

• Better than your peers who after A levels or junior college went on to choose other careers?
• Better than what your parents managed to provide for you when you were growing up or that you can provide for your children better material comforts than what your parents provided for you?
• Better than what your seniors in the medical profession could achieve?
• Better than what your classmates in medical school could achieve?

Whether we like it or not, most of the time, this “better” involves material possessions and wealth. Of course, there are a few who do not consider measures of material wealth being pertinent at all; these include admirable folks who go on to work in NGOs, become missionaries etc. But these are the exceptions.

Also, a lot of what a better life depends on where is your starting point. If you grew up in a 2-bedroom rental Singapore Improvement Trust flat or a 3-bedroom HDB flat and taking the bus to school, then buying your first executive condominium at 32 or your first small second-hand car at 30 usually means medicine has indeed given you a better life, materially speaking.

But if you grew up in a freehold landed property in Districts 9, 10 or 11 and you were fetched to school by your parents or even chauffeured in a nice big car from Primary 1 to JC2, then ending up in an executive condominium and buying that small second-car car as a medical officer is not a big thing. In fact, you may start to wonder if being a doctor will ever lead you to a “better” life, without parental assistance in the form of paying for the down-payment of the condominium and/or helping you with paying for that $100,000 Category A COE. And then you may even start to doubt if you will ever make it to a Category B COE vehicle in your lifetime, given how things are going.

What constitutes “a better life” is a tough question that each generation of doctors have to face and answer themselves. Because no one can answer these questions for them.

But the facts are not on young doctors side. 30 to 40 years ago, 150 to 200 students were chosen to read medicine locally out of a cohort size of about 60,000. Another maybe 30 to 50 kids were rich enough to go overseas. In other words, about 200 to 250 medical graduates were produced a year from local and overseas medical schools. Today, a total of 700 medical graduates are produced a year (500 local and 200 overseas), out of a cohort size of about 35,000 to 39,000.

Put it another way, when this hobbit entered medical school, there was one doctor to 1000 persons in Singapore. Now there are 2.7 doctors to 1000 persons. This figure is likely to reach 3 in a few years’ time. While an ageing or aged population will create more demand for medical services, it is unlikely to fully offset the effect of a quickly growing medical profession. In other words, there will be less work for each doctor, which will likely translate into less earning power.

You can see it especially in the private specialist sector. 30 to 40 years ago, nobody really worried about not enough work when they went private. 20 years ago people worried a little but in the end, nobody was short of work either. Today, not having enough patients is a real concern.

The public sector is not spared either. Recently, a senior public sector doctor posted in social media that 25% of doctors in public hospitals were senior consultants. Senior consultants used to be a rarity, now no longer. I hear in some top-heavy tertiary hospitals some consultants only have half a day of operating theatre time a week.

Doctoring is no longer an uncommon thing, like in the past.

We always say medicine is a calling. Only those that receive that calling should become a doctor. This hobbit still believes this to be true. But we need also to be honest and admit if we use the old perceptions and definitions of what a better life is, then medicine is unlikely to deliver the goods for many doctors. And young men and women who aspire to be doctors today should know these hard truths before committing to a career in medicine.

They will need to decide for themselves what are the new norms for defining a better life. And that may already be taking place even as we speak. Maybe that’s why young doctors now talk about better work-life balance and quality of life. Because these are the ingredients for a better life that they can still hope for today.

According to some folks, in a “perfect world”, doctors prescribe and pharmacists dispense. Doctors earn only from consultation and pharmacists make a living from drug mark-ups, whether from sales or dispensing. Unfortunately, the world is not perfect. Our colonial masters saw it fit to let doctors and medical clinics dispense medicine to their patients, which actually ran counter to what was happening in the United Kingdom when we were still a colony.

And since then, doctors made a living out of both consultation and the dispensing of drugs here. I stress, it is dispensing and not sales, since we are not allowed to “sell” medicines to persons who were not our patients and only allowed to dispense medicine to persons with whom we have a doctor-patient relationship. And this even applies to Over-The-Counter (OTC) drugs.

Despite the fact that doctors are allowed to dispense medicines and derive some profit from it, it is not a carte blanche. There is always competition from pharmacies and patients have a choice. Patients can always decide to take a prescription from a doctor and get it filled at the pharmacy, especially if the price of the dispensed drug is higher than the pharmacy price. This is already happening as many Singaporeans get their chronic medication prescriptions filled across the border in Malaysia, where medicines are cheaper due to territorial pricing practiced by many pharmaceutical companies.

And before the Competition Commission of Singapore in their infinite wisdom decided to outlaw the SMA’s Guideline of Fees, the SMA actually put out guidelines on how to mark-up medicine prices. The Hobbit has reproduced these withdrawn Guideline on Medicine Fee which was issued in 1998 in the second section of this post (which in turn was reproduced in the June 2001 issue of the SMA News that is available on the SMA website).

But the hard truth remains:- GPs in the private sector have never been able to make a living just from consultation fees alone, and their earnings are significantly augmented by dispensing activities.

So the recent informal discussions between the bureaucrats and various GP leaders and PCNs (Primary Care Networks) have resulted in a lot of angst and unhappiness. The main point of contention is the (draft) Drug Whitelist and the price-caps for each drug in the Whitelist. Those GPs who have seen this list have largely come to the conclusion that if they followed the price-caps, it would result in a very significant loss of earnings for them. The counter-argument is that the loss of dispensing earnings would be offset by various payouts from MOH for managing what are called these “chronic enrollees” appropriately.

Most GPs unfortunately remain unconvinced by this counter-argument. From the GP’s perspective, the reasons for the scepticism are at least three-fold:

• A bird in the hand is worth two in the bush. The GPs are now earning decent margins from dispensing activities, while participating in the treatment of chronic enrollees will definitely lead to an erosion of margins and loss in earnings. The GP has got to earn more money from MOH payouts from other Healthier SG activities to address this loss in earnings. To qualify for these payouts that range from $130 to $180 a year for each chronic enrollee, several milestones have to be reached. These are reasonable milestones from a clinical standpoint, but the reaching of these milestones require the full cooperation of the patient. And as any experienced GP will tell you, patients may not cooperate with you fully for a host of reasons best known to the patient. There is therefore much uncertainty in this.

• There is no guarantee from any other party as to the number of new enrollees each GP will get. Participation is strictly voluntary for the patient. MOH or the clusters will not forcibly assign any new patients to any GP. In the worst-case scenario, a GP may get no new patients and his existing patients are converted into Heathier SG chronic enrollees and hence subjected to strict price-caps when whitelisted drugs are used. In effect, a GP is subjected to unilaterally offering price guarantees without a corresponding guarantee of any significant increase in business volume from other parties. (Unfortunately, repeated expressions of “don’t worry” do not amount to a business guarantee in real life)

• The GPs think they know their business better than anyone else and therefore they think they are right. (The counter-argument suggests that the bureaucrats think they know the GP’s business better). And what is worse, should the GP be right, no one will compensate them for the loss in earnings. In other words, they bear most, if not all of the business risk of this grand endeavour.

In conclusion, to the GP, the price-caps of whitelisted drugs, as it stands now, represents a very high-risk venture with probably a limited potential upside.

My Chinese teacher once said this to my class – people may risk their lives to take part in very lucrative but illegal businesses (like drug-trafficking), but no one will take part in businesses that will in all probability lose money.

As the current design of the whitelist stands, the patient stands to benefit a lot while MOH meets all its KPIs and strategic goals. Unfortunately, it appears that one rather important aspect has been not taken into adequate consideration, which is how the GPs benefit from this.

Because we GPs are simple folks thinking simple strokes), it’s rather simple to see what is important to the GP, (assuming quality healthcare is given to their existing patients already):

1. Do you give me assured business leading to increase business volume and revenue?
2. Do you increase my earnings?
3. Does participating in your scheme cost me much (Not just money, but in terms of time and effort as well)?
4. How much business risk do I bear in this endeavour?
5. Do I keep my business and professional autonomy?

Of course, we don’t expect all of these above considerations to be in our favour and there is a lot of give and take. For example, if you guarantee me extra business at no business risk, I don’t mind sacrificing some of my autonomy and even investing a bit here and there to upgrade my practice, say, on the IT side.

But if I cannot be assured of an increase in earnings and yet have to put in a lot of effort, such as keeping two sets of stocks and dispensing records as well as financial accounts for Healthier SG and non-Healthier SG patients for the same whitelisted drug, (as is what is being proposed now), then it is quite likely that I will decline to participate. Especially when I am stuck in my 680 square-foot HDB shophouse practice and I really, really have no space or manpower for this kind of fancy logistic and accounts management. (This hobbit has this strong suspicion that whoever came up with this has never been to a HDB estate to see a GP in his/her life and this person should be sent to Tengah New Town to oversee a setting up of a GP practice as part of his private sector and/or community engagement posting).

Therefore, I would rather keep my bird in my hand than to go for the two in the bush. As it is, my bird is a rather small one already, (compared to my specialist colleagues), I cannot afford to lose this one little bird while hoping to find others in the bush. In other words, I am very risk-adverse.

Finally, there is a saying by Lao-tzu (attributed as the founder of Taoist philosophy) that goes like this, “If the water is too clear, there is no fish”. Perhaps the water is indeed too clear with the Drug Whitelist and price-caps, and the fish are unwilling to come out and be seen.

Indeed, if you compare the price-caps, allowed percentage markups and margins of the Drug Whitelist with the withdrawn 1998 SMA Guideline on Medicine Fee, you will realise in many cases, the 1998 Guideline offered a better deal for even the very low-cost medicines then than what is allowed 25 years later, for the GPs treating chronic-tier enrollees. And it bears remembering that in the nineties, my bowl of mee pok only cost $2 in Houseman Canteen, SGH.

SMA Guideline on Medicine Fee (Issued in 1998, Withdrawn in 2007)

a) The price of medicine to the patient should be comparable to what he would have to pay, if he were to choose the prescription at a pharmacy instead.

b) Prices comparable to those charged at a pharmacy are an acceptable upper limit. When this is not known, the following are some suggested acceptable alternatives:

1. When the price of the medicine is listed in a drug index such as DIMS, the list price of the single-user pack size can be used.
2. When the above is not available, the list price quoted by the manufacturer or the distributor can be used. When this list price is not available, up to 1.25 times the nett price for the single-user pack size is acceptable.
3. Where neither the list nor nett prices of the single-user pack size is available (e.g. bulk-packed medicine). Up to twice the per-unit cost of bulk-packed medicine is acceptable.
4. For very low-cost medicine, a rounding up to 10 cents per tablet/capsule, $1.50 per 5g of cream, or $1.50 per 30ml of mixture, is acceptable. Alternatively, a rounded-up charge of $2 per each medicine dispensed for up to a week, is acceptable.

c) The patient retains the right to choose whether to fill the prescription in the clinic, or externally at a pharmacy.

This Hobbit is appreciative of how the government has recognised folks and organisations that have contributed to the battle against the Covid-19 Pandemic by giving out Covid-19 National Awards. But it is important to not just recognise these worthy people and organisations but also to recognise those that were not given. So we start off this year’s Hobbit Awards by giving out

The Covid non-Award Award (Category A)

This award goes out all the Permanent Secretaries in government. Other than the Permanent Secretary for Home Affairs and Chairman of the Homefront Crisis Executive Group (same person), none of the other Perm Secs were given any Covid-19 National Award by the government. This hobbit speculates that this glaring omission could only be so because all of them declined to receive any award and only put up the person chairing this powerful Group to receive the award on behalf of all of the others. If so, nice move. I like.

The Covid non-Award Award (Category B)

The President’s Certificate of Commendation is a new award category. It is given to “organisations and teams that made exceptional efforts which had a significant impact in Singapore’s fight against COVID-19”.

481 certificates were given out and this hobbit has no doubt that all of them deserve the award. These include not just teams and departments in the public sector but private companies and NGOs as well. Some recipients include the College of General Dental Practitioners, the General Insurance Association (GIA), the Life Insurance Association (LIA), The Association of Banks in Singapore (ABS), The Association of Funeral Directors Singapore (AFD) and The Law Society.

Interestingly, none of the major healthcare professional associations such as the SMA, Singapore Dental Association (SDA), Pharmaceutical Society Singapore (PSS), The College of Family Physicians Singapore (CFPS), Academy of Medicine Singapore (AMS) and Singapore Nursing Association (SNA) received the President’s Certificate.

To all these big healthcare-related professional organisations that didn’t receive this prestigious President’s Certificate, never mind lah, this hobbit gives you the not-so-prestigious but very sincere “The Covid non-Award Award (Category B)”

Now, we move on to other awards for 2023

Community Destruction Award

There is a certain private hospital that has either closed or is in the process of closing down the fruit shop, retail pharmacy, doctors’ tea room and a busy branch of a bank located on its premises. This hobbit hopes the management of this hospital knows that when you run a large hospital, you are actually managing a community and fostering its community spirit, and you are not just operating a facility. A community is made up of people. A facility is just brick and mortar.

Once Bitten Twice Shy Award

On 29 Nov 22, Senior Minister of State Dr Koh Poh Koon rejected a proposal by the General Insurance Association (GIA) to “tweaking existing insurance products” to cover gig workers such as ride hailing and on-demand delivery workers as this would lead to higher costs for the platform companies that hire them. (Business Times, 29 Nov 22 : General insurers’ proposals for gig workers not viable or cost-effective: Koh Poh Koon).

More importantly, it was reported in this article that he said, ““GIA’s suggestion of using only existing prolonged medical leave insurance or group personal accident insurance in place of Wica would relegate this to a private insurance policy whose terms and conditions are dictated by the insurer, without a clear mechanism to adjudicate disputes,” he said. “I appreciate why insurers would want more flexibility in how they compensate claims but to ensure fairness to workers and companies, I do not think we should be leaving it to insurers to be the final arbiter of any disputes to work injury claims,” he added, citing possible conflicts of interest.
Dr Koh said the committee also engaged platform workers, who described having to “jump through hoops” to make claims, even giving up on doing so due to the onerous process””

Sounds familiar? His words can also be an accurate description for many cases involving Integrated Shield Plans now, where a platform supposed put in place to handle disputes are voluntary and IP providers can refuse to take part in them. In this hobbit’s opinion, when you can refuse to participate, you are effectively the “final arbiter”, even if a process exists.

Obviously Dr Koh has learnt a few things during his stint in MOH and has now applied them with great clarity in MOM. Bravo. He gets our Once Bitten Twice Shy Award hands-down.

Incidentally and as aforesaid, the GIA received the prestigious President’s Certificate of Commendation (Covid-19) just a few days ago.

Great Singapore Sale Award

The Annual Great Singapore Sale has been in the doldrums for a long time, worsened by the impact of the pandemic. Well, this year’s Sale promises to be briskier and earlier, with relatives and friends of Mainland Chinese buying paracetamol and other flu medicines by the cartloads in Singapore and shipping them back to the Mainland. This hobbit finds it strange that China is supposed to be the Factory of the World, yet they cannot produce enough paracetamol and distribute them accordingly within China?

Most Unwelcome Sequel Award

As Covid-19 Omicron and its variants reap their way through way through China like a ravenous sickle, one cannot but fear that new variants will be created. Just as it happened with Delta in India and Omicron in South Africa. Can China, with its 1.4B population avoid this fate? Will the current China wave prove to be the most unwelcome sequel to Delta and Omicron?

Best Evidence Award

According to Johns Hopkins University statistics, the number of Covid-19 deaths is about 11,800+ deaths in HK so far, arising from a base of 2.6M cases. Most of the deaths occurred during February and April of 2022, peaking on 11 March when 294 deaths occurred in a single day. In Singapore, there have been about 1700+ deaths from a base of 2.2M cases, with deaths a day peaking at 22.

HK’s population is about 37% larger than Singapore’s (7.4M vs 5.4M). Using Singapore Covid-death numbers as a base (1700), it can be extrapolated that HK’s death numbers could have been around 2400 (1.4 x 1700). Instead there are 11,800 deaths or 9400 “excess deaths” when compared to Singapore. These deaths can be largely attributed to a lower vaccination rate among the elderly and a sizeable population receiving less effective vaccines.

These are the numbers that any anti-vaxxers have to satisfy themselves with intellectual honesty that vaccination is bad for people, especially for the elderly before continuing with their counter-truth messages.

Mental Sclerosis Award

There is a nursing shortage worldwide. This country has lost and is still losing nurses, especially foreign ones to other countries that offer superior terms. Either we shape up and rethink how we can keep our experienced foreign nurses or we will have to suffer this continual drain until some crisis occurs (if it hasn’t occurred already). Superior terms do not just include a bigger pay package or more allowances. Superior terms include non-monetary terms, e.g. the ability to bring their family, especially kids along with them to Singapore and to give them access to subsidised education and healthcare.

Also, you really can’t replace a nurse with 5 to 10 years of working experience in our hospitals with a fresh recruit. It takes several years before a foreign nurse understands our working environment and attains a high degree of local-context proficiency. So this explanation that we can address the situation by recruiting 1000 nurses from overseas to replace the 1000 we lost recently doesn’t quite cut it with operators on the ground who know better.

Of course there will be people who will argue that we cannot give these foreign nurses superior terms that are different from workers drawing the roughly the same salaries but working in other sectors and jobs.

To these people, this hobbit confers the Mental Sclerosis Award. Hopefully these folks will never be admitted to a hospital in their entire life and then know what it is to be a patient in an environment that is short of experienced nursing manpower.

Ugly Neighbour Award

Remember how many people criticized the government for not imposing test requirements, restrictions and bans on flights originating from India early enough in the first half of 2021 as the Delta variant (which was first discovered in India) swept through the globe?

Well, obviously India has learnt something from what Singapore did then – it has now very swiftly (on 29 Dec 22) imposed a mandatory negative Covid-19 test result requirement from just 6 places – China, Japan, Hong Kong, Thailand, South Korea and Singapore. This is to address the large number of cases that are popping up now with the current Covid-19 sweeping through China.

When this old coot of a hobbit was growing up decades ago, this conversation wasn’t quite uncommon or unexpected –

The hobbit, “Hi, I am hobbit from Singapore”,
Reply from American, “Oh, that’s a nice place in China!”

Maybe the Indian authorities today still think likewise.

Coming of Age Award

A generation of doctors was baptised with blood, toil, tears and sweat during the SARS Outbreak of 2003. Another generation of young doctors have since been tested with something far more persistent, pervasive and pernicious than SARS. Their scars may not completely heal even with time and the loss of years and innocence cannot be retrieved. But they continue to stand proud and tall. Going forward, this hobbit has no doubt that they will be more than capable of taking up the mantle of the medical profession from their seniors. They have come of age amid The Pestilence Of This Age.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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