On the day after the Budget was delivered by the Finance Minister (19 Feb 2022), an important infographic appeared in The Straits Times. It showed something that this hobbit didn’t think he will see in this lifetime.

It showed that MOH now had the biggest budget in the government – S$19.29B, even higher than MINDEF, which traditionally had the biggest budget all these years. For the coming government Financial Year, MINDEF’s budget was $16.36B. In third place was Ministry of Education (MOE) at $13.6B. Traditionally, MINDEF and MOE always had the biggest and second biggest budgets in government.

MOH’s budget is going to grow by 4.7% from last year and takes up 18.8% of Total Expenditure (estimated to be $102.41B). This $102.41B is carved up by 15 ministries as well as Organs of State and the Prime Minister’s Office making a total of 17 buckets. But MOH’s bucket alone takes up 18.8%, almost a fifth of total expenditure.

One can say that well, we are in the middle of a pandemic and everyone is spending a lot on health, which is true. But there is no denying that even without the pandemic, MOH budgets over that 15 years or so have been growing very quickly. In 2007, government healthcare expenditure was 2.283B¹; by 2019 (the last year before Covid-19 struck) this had risen to 11.147B. In other words, between 2007 and 2019, a period of 12 years, government healthcare expenditure grew 4.9 times. Put in the effect of Covid-19 and over a longer period (from 2007 to 2022), government healthcare expenditure is expected to grow by 8.4 times in these 15 years!

Some of this growth along the way can also be attributed to a change in strategy for healthcare funding. In 2013, the government decided to raise its share of total healthcare expenditure from 30% to 40%, which was the correct thing to do as the population aged rapidly.

So it is of little surprise that the Health Minister announced MOH’s strategy for the next 10 years in this year’s Budget – Healthier SG

He outlined the five pillars of Healthier SG –

• Activate Family Physicians (FP) Networks – Everyone should have a FP
• Everyone Should Have a Care Plan with heavy emphasis on prevention
• Community Partnerships
• And if the above three are in place, then everyone can take part in a National Healthier SG Enrolment Programme
• Structures and policies to support healthcare reform, e.g. Manpower, IT, Finance

A White Paper will be presented in Parliament to debate Healthier SG. The need for Healthier SG can be reduced to two main factors – a fast ageing population, as well as a population that is getting unhealthier. To underscore this second point, he said pithily in Mandarin, “what should be high is not high, and what should be low is not low”. (Somehow when this is said in English, there’s no kick)

Also indicated in not so big print is that with the National Healthier SG Enrol Programme, capitation can be explored and that each cluster can enrol up to 1.5M patients.

Chope. Wait. Tunggu. 等。

Capitation. A four syllable word that can trigger some serious action potentials in many a doctor’s neurons.

It would seem we are moving from paying for workload to capitation. And we have heard some horror stories about capitation from overseas examples. These would include, just to name a few:

• Hospitals avoiding expensive, complicated cases and pushing the work to other providers. For example, how would national specialty centres be funded for the management of complicated cases and provision of tertiary care?

• Hospitals running out of money before the funding cycle is up. For example in some places, when there is no more money, public hospitals then stop total knee reconstruction surgeries in the last two to three months of the year.

• Insufficient funding for cutting edge medicine as hospitals thereby leading to erosion of excellence.

• While clusters are paid by capitation, how would healthcare workers, especially specialists be paid? Will they be incentivised to see more patients or not under a capitation system?

• Will patient choice be limited? Currently, a patient can theoretically go to a NHG Polyclinic in the morning, go to a Specialist Outpatient Clinic in a Singhealth hospital in the afternoon and then to a NUHS Hospital A&E at night. If patient choice is not limited, how will capitation work under such circumstances? Can better efficiencies be realised without limiting patient choice?

These questions are not new and have been asked in other countries that have adopted a capitation financing model. The truth is there are pros and cons, strengths and weaknesses to both capitation and pay-for-volume models. Some have avoided the worst and adopted the best of both models and lived to tell the tale. But not many. How will we fare? This hobbit wishes the best for those policy wonks working in the White Building; the folks that have to come up with the White Paper. Incidentally, the last time MOH has published a While Paper was in 1993: “Affordable Health Care” White Paper. Yup, it’s so long ago “health care” was spelt in two words and not one word, i.e. “healthcare”. Anyone with any memory of contributing to this White Paper in MOH would have taken their CPF or pension by now…

Of particular local interest is how will patients be split among the three clusters. The minister has said that each cluster can enrol up to 1.5M patients. But the truth is one cluster is significantly larger than the other two. How will the work and financing be split?

Putting the issue of capitation aside, this hobbit is most heartened that prevention is put front and centre. It remains to be seen how GPs and Polyclinics will be funded to achieve better disease prevention for all. As we all know, results of these efforts will not manifest early. It may be years before a healthier Singapore materialises. So it is important for politicians and policymakers to stay the course even when early and interim outcomes are not encouraging.

Onto another aspect of the Budget debates. NMP aka SMA President Dr Tan Yia Swam asked what was MOH’s position with regard to managing or regulating Third Party Administrators (TPA). The answer given was “We are monitoring the situation”. Turns out that that was the same answer given 6 years ago to essentially the same question. Ooops. Monitor so long, still monitoring? What has been monitored and what is the outcome of this very long monitoring? Anyway, Dr Tan’s suggestion to this long-term monitoring is that maybe it is time for MOH to be more “proactive” than just monitoring. This hobbit cannot agree more.

Actually to this hobbit, the whole thing is quite simple. When you have a problem, you have to regulate all major parties such they have skin in the regulatory game. Take gambling – you have a regulatory framework that covers the problem gambler, the legal gambling providers, including casinos, Singapore Pools etc and includes punitive and enforcement action against illegal or unlicensed gambling providers as well. Similarly, for smoking, you regulate the folks that import and sell cigarettes and the smokers and even the potential future smokers (i.e. the young adults and teenagers).

But when it comes to TPAs and their commercial arrangements with doctors and their corporate customers, only the doctor is subject to any regulation (through the SMC). It would seem that ONLY doctors have the responsibility and obligation to ensure the system stays ethical and clean. The TPAs have no such responsibility or legal obligation whatsoever. In many regulatory regimes, a good regulatory approach is often cited as “multi-pronged”, “comprehensive” etc. But when it comes to managing TPAs, it is uni-pronged and one-sided – Just regulate the doctors and everything will be fine. That’s wishful thinking isn’t it?

You will NEVER solve the problem with this one-sided approach even if you monitor the situation to kingdom come. In fact, the current TPA milieu may just impede the smooth implementation of programmes and policies that are necessary for a Healthier SG.

Finally, a follow up on the last post “A Tale of Two Cities”. Since that was posted, things have gotten rapidly worse for Hong Kong, unfortunately. How bad?

On 1 March 2022, both places had roughly the same number of Covid-19 deaths. Singapore by then had recorded a cumulative total of 1030 deaths; HK had a total 1013 deaths from public hospitals (according to the Hospital Authority). There are probably more deaths than 1013 since a small number of deaths occurred outside of HK public hospitals, but let’s just stick to a discounted number of 1013 for now.

14 days later, as of 15 March, Singapore has 1153 deaths while HK has recorded a staggering total of 4568 deaths. HK has a population of 7.6M, which is 36% larger than Singapore’s 5.6M. For the purpose of comparison with HK, lets add another 36% to Singapore’s 1153 deaths to give a weighted total of 1568 deaths. In other words, we assume that had Singapore had a population of 7.6m (Similar to HK), it would have recorded a total of 1568 deaths on 15 March 2022.

There is nothing to indicate that HK’s hospitals and doctors and nurses are any inferior to Singapore’s. The age group distribution profiles of the two places are roughly similar. In the period of 14 days, HK has logged an excess of 3000 deaths (4568-1568=3000) over Singapore’s weighted number of 1568 deaths.  That’s an excess of 214 deaths a day over 14 days. This difference can be largely attributed to the fact that they had a much lower vaccination rate for their elderly and for residents of nursing and elderly homes. This point was admitted to by Chief Executive Carrie Lam herself when she said the efforts to get the elderly vaccinated were “not enough” and the vaccination rates for these groups were lower than “China, Singapore and certain European countries” just a few days ago. The difference between vaccination rates for HK and Singapore’s elderly is best represented by the charts in this article² which in turn was first published in the Financial Times.

Sometimes the human mind cannot quite fathom what exponential growth is. To give an example, on 1 March it was reported in Bloomberg that according to an updated forecast from the Laboratory of Data Discovery for Health and the University of Hong Kong’s WHO Collaborating Centre for Infectious Disease Epidemiology and Control, “the cumulative number of deaths by the end of April (emphasis mine) could be around 4,645″. (Hong Kong’s Covid Death Rate is Now One of the World’s Highest, Bloomberg, 1 March 2022) Well, its the middle of March, and we are already at 4,568.

The hobbit is NOT highlighting the mistakes that HK may have made in their pandemic fight for the sake of making Singapore look good or HK look bad, but rather to make the point to all these rabid anti-vaxxers out there in Singapore (and there are still quite a number lurking around) that had the government and people of Singapore listened to their anti-vaccination rhetoric, then we may well have more than 4000 Covid-19 deaths by now as well. The hobbit derives no joy at all from what is happening to HK, a place he happens to like very much, but unfortunately there are quite a few tragic lessons that HK has in store for us now which we must learn from. Every death is tragic, let alone 3000 excess deaths.

¹https://www.moh.gov.sg/resources-statistics/singapore-health-facts/government-health-expenditure-and-healthcare-financing (accessed 12 March, with link to excel spreadsheet)

²https://yourlocalepidemiologist.substack.com/p/state-of-affairs-march-14

And just like that, we are now into March 2022. Quite a few things happened in February 2022.

A little known fact is sometime in late February (around 27 Feb 22), we crossed the fateful number of 1000 Covid-19 deaths in Singapore, some 25 months after the first case landed here. This hobbit suspects that we are now at the peak or near the peak of the Omicron wave. We are now chalking up 15,000 to 26,000 cases a day and daily deaths number from the teens to the twenties. Based on these rough numbers, the case fatality rates of Omicron can be estimated to be about 0.1% in Singapore, approximating that of the seasonal flu. There are two caveats to this number of 0.1%:

• fatalities usually lag behind case number by two to four weeks, we could yet see a rise in fatalities in the coming weeks
• the number of cases is probably an underestimate as many cases now go unreported under Protocol 2: the infected self-test and stay at home for 3 to 7 days without being captured by official data collection methods.

The number of ICU cases have also remained relatively stable, in the range of 40 to 50 cases a day. We have about 350 to 400 ICU beds in the system and the strain imposed on ICU beds by Covid-19 patients is largely bearable. The real issue is at the primary care and A&E level where doctors are swarmed by many patients, many of which have no or mild symptoms.

Meanwhile in Hong Kong (HK), a city that Singapore is often compared with for anything ranging from property prices to wanton noodles, the situation is getting grimmer by the day.

On 2 March 2022, HK has already chalked up 1168 deaths¹, surpassing that of Singapore (1030 deaths as of 1 Mar 2022)². This in itself is not surprising because HK has a larger population than Singapore. But the momentum of this current wave is just simply all-consuming. Up till 2 March, HK logged a very respectable total of 293,730 cases, but just for the last four days (27 Feb, 28 Feb, 1 Mar and 2 Mar) the case numbers were 26,026; 34,466, 32,597 and 55,353 respectively, making a total of 93,090 cases. The daily deaths in the last three days were 83, 87, 117 and 116, making a total of 403 cases. In other words, 34.5% of Covid-19 deaths and 39% of Covid-19 cases occurred in the last four days. If that isn’t frightening, I don’t know what is.

It is interesting to note that Singapore has 748,504 cases as of 1 March, about three times that of HK, but the number of deaths are about the same in both places. In other words, ignoring the underdiagnosing of cases in both places, the case fatality rate in HK is three times that of Singapore.

One reason to explain the difference could be that in 2020, large numbers of young healthy foreign workers were infected in Singapore. Very few of them died and this would lead to a lower overall case-fatality rate in Singapore. But this cannot explain the difference entirely.

Another reason could be that it is a well-known fact that when hospital systems are overwhelmed, fatality rates increase. That could be happening in HK now, and that is why we see mainland China rushing in resources to help HK cope.

The other very important factor is that vaccination rates in HK are pretty low among the elderly. About 77% of those eligible have received at least two doses of vaccination. A good number, but not as high as the corresponding figure of 94% for Singapore.

What is really problematic is that it is estimated that at least 40% of those 70 and older have NOT received two vaccination doses. In other words, the folks who are the most vulnerable, who need vaccination most are also the people least likely to have received any or adequate vaccination. Only 30% of those above 80 have received 2 doses and 59% of those aged between 70 and 79 have received 2 doses. The corresponding numbers for Singapore for these two age groups are 94% and 96% respectively

This has been a walking timebomb ever since vaccination was offered in early 2021 in HK. And now this timebomb has exploded.

The principles of communicable disease control remain the same even as pathogens change. These principles are destroying the source of pathogen, breaking transmission, treating and isolating the infected and protecting the susceptible, i.e. vaccination. Breaking transmission such as social distancing, wearing of masks etc worked well in the early phases of the pandemic because the original Covid-19 virus was not as transmissible as the later variants. The basic reproduction number R₀ was estimated to be about 2.7 for the original variant. That number increased to 5 for the Delta variant. For the Omicron, it is estimated to be at least 7. In other words, one Omicron patient is estimated to infect at least 7 other persons.

For perspective, the R₀ for seasonal flu is 1.2; for smallpox it was 3; polio: 4 to 6. Very infectious diseases such as mumps and chickenpox will have a R₀ of 10 to 12 and measles 12 to 18. Another way to look at it is the doubling time. The doubling time for the original variant is about 7 days, while for Omicron, it is down to 2 to 3 days.

The doubling time and R₀ numbers for Omicron suggest that it is far more infectious than the original variant of early 2020 or even Delta. What that means is that the old strategy of breaking transmission by wearing masks, handwashing and social distancing etc will become more and more ineffective in stopping Omicron vis a vis older variants.

Another way to look at it is that in order for transmission to be effectively broken, the costs of doing so will become more and more prohibitive for Omicron when compared to earlier variants, i.e. with a R₀ of 7 compared to 2.7, one would need more and more draconian policies and measures to be put in place to break transmission.

But this need not be so if a higher vaccination rate is achieved. While it is true that higher vaccination rates do not prevent infections in many cases with the current Omicron wave, the truth is it does reduce the number of infections significantly. And it certainly dramatically reduces the number of seriously ill or ICU cases. Because of our high vaccination rates among all age groups including the elderly, this hobbit will wager that Singapore is not going to see 100 deaths a day in this round of pandemic with the Omicron variant. It is also very unlikely that we will reach 50,000 cases a day, but this hobbit won’t rule that out completely for now.

So to all those anti-vaxxers out there who still insist vaccination is a bad thing, just observe what is going on in Hong Kong now. They already have a high vaccination rate, but they are still being hit badly now. The vaccination rate just wasn’t high enough amongst the most susceptible – the elderly. The lesson here is every shot makes a difference and it all adds up, especially for the susceptible groups.

My prayers go out to HKers, especially to our fellow healthcare workers there who are in for the fight of their lives. HKers are a resilient bunch and this hobbit knows that they will rise from the ashes of this crisis stronger. As for us, it ain’t over yet. But even as daily numbers hit more than 20,000 cases, there is no need to press the panic button yet.

¹https://chp-dashboard.geodata.gov.hk/covid-19/en.html (Accessed 2 Mar 2022)

²https://covidsitrep.moh.gov.sg/ (Accessed 2 Mar 2022)

Before we know it, the nation is ambling towards the end of 2021. If you ask this hobbit, 2021 was even stranger than 2020. There wasn’t the shock and awe that inevitably accompanied the advent of a new pandemic. The fear is still there, but fear, like a fixed cost, sort of diminishes with time and vaccinations, replaced by an all suffocating sense of morosity, vexation and weariness.

Anyway, speaking of vexation, recently, there was a report about how a doctor was vexed when a 99-year old Covid positive patient died at home and the family experienced problems with procuring undertaking services immediately after the death. (The Straits Times, 1 Nov 21). A director from the MOH in charge of Aged Care Services replied that it need not have been so, “our (MOH?) processes allowed him to be conveyed to the mortuary but the undertakers were reluctant to do so”. He further said that “Many of our undertakers have undergone infection control training by the National Centre for Infectious Diseases, many may still be concerned about managing those who die of Covid-19”. (6 Nov, ST Forum)

In a rare case of factual rebuttal, the Secretary of Association of Funeral Directors Singapore wrote in the same ST Forum the next day, “Funeral directors, as of now, are permitted to handle bodies of Covid-19 patients only at hospital mortuaries. Even the casketing of the body has to be done on the mortuary services. The regulations do not allow funeral directors to do this anywhere else”. He added, “In Mr Teo’s (i.e. the deceased) case, the funeral director who was asked to assist but did not was complying with regulations set out by MOH. The funeral director would run afoul of the law if he had proceeded to move Mr Teo away from the residence”. He then stated the obvious, “If we are to allow persons with Covid-19 to undergo home recovery, we need to accept that some people will die at home”.

Ouch.

To-date, this hobbit is not aware that MOH has published any reply to this letter from the Association of Funerals Directors Singapore yet.

If only the dead could talk, maybe we should ask them about how they feel about this whole affair.

Going past the irony and pathos of the whole situation, this hobbit notes than 171 circulars have been issued so far. Actually, probably more than 171 circulars have been issued because nowadays MOH may issue “secondary” releases of circular on the same subject matter with an alphabetical suffix. E.g. In addition to Circular 170, there could be 170A and 170B and so on.

In 2020, 244 circulars were issued. In other words, probably 400 circulars have been issued since the pandemic began and Singapore saw its first case of Covid-19 infection on Jan 2020 till now. Of course, not all circulars are Covid-related, but the majority of them certainly are.

I guess with time, even the people who drafted these circulars and the issuers of these circulars may have forgotten about the content of earlier circulars. After all, events of a year ago seem a lifetime away. Alert readers of this blog may recall that it was on 28 Dec 2020 (i.e. Phase 3), that folks were allowed to dine in up to a group size of 8.  11 months later, eating in a group size of 8 seems like something so remote that it almost sounds bizarre.

The other possibility is that the whole thing has gotten so complex that different stakeholders may not be aware of what other stakeholders are doing. For example, the disease control folks have a set of concerns that could be quite different from the aged care people.

So this hobbit is not surprised one bit when the Director of Aged Care Services doesn’t seem to be aware of the MOH-issued prohibition on funeral directors to handle the bodies of Covid-19 patients outside of hospital mortuaries.

We now move on to the other big happening of November 2021, which is the announcement on 9 Nov 21 by MOH of the setting up of the Clinical Claims Resolution Process (CCRP) platform to resolve disputes among Integrated Shield Plan (IP) policyholders, IP providers and doctors. Tandem with this announcement is the commitment declared by IP providers to increase the size of their preferred provider (i.e. doctors) panels.

The CCRP is essentially a mediation platform. When disputes are filed and the stakeholders agree to go through CCRP for mediation, a CCRP Panel consisting of two medical director representatives from IP insurers and three relevant specialists chosen by the Academy of Medicine Singapore (AMS) and a non-voting representative from Consumers Association of Singapore (CASE) is formed to assess the case.

The hobbit thinks this is a significant development in both the patient’s and doctor’s favour as they seek a more level playing ground against the mighty IP providers. For one, hitherto to this, clinical issues really have nowhere to be addressed expeditiously unless one has the resources and tenacity to mount a law suit. The overarching insurance regulator, MAS, appears to be only interested in the financial viability of IP providers. MAS is either not equipped or has not shown any desire to be equipped with the knowledge and skills to deal with the clinical aspects of IPs. MOH, on the other hand, is also not the appointed administrator of legislation that directly oversees insurance company regulation. So clinical matters, such as whether a procedure should be reimbursed or not on clinical grounds, is really in no man’s land until now.

The other big development in the IP milieu is that IP providers have committed themselves to increasing the size of their doctor panels. At the beginning of this year, all IP providers, other than Raffles Health Insurance have panel size in the region of 300 to 400. By the end of 2021, these same IP providers are committed to having panel sizes of between 450 to 600. This is a step in the right direction. But there is still much room for improvement.

According to The Straits Times report “Give patients in Singapore better choice by having insurers share a common pool of panel specialists”, there are 1,235 specialists in the private sector who are eligible for empanelling. Since practically no one buys IP from more than one IP insurer, it means any policyholder only has less than half of eligible specialists available to him at any time should he need care to be covered by his IP.

Nonetheless, both the CCRP and the increase in doctor panel size are positive developments. It is therefore important to ask how have these positive developments come about and why.

Even before Covid-19 hit our shores, many private sector doctors have expressed disappointment with how some IP providers were conducting their IP business in terms of pre-authorisation processes, reimbursement rates and doctor empanelling. As far as this hobbit knows, all this came to naught as the doctors’ grievances fell on deaf years and were met with stonewalling.

Things only started to move after the 61^st Council of SMA decided enough was enough and crossed the Rubicon on 25^th March 2021 by issuing a Position Statement on “Troubled Integrated Shield Plans”.

This Position Statement

• Described the historical context and development of IPs from the 90s till present, and explained how many of the problems faced by IPs were really of their own doing, when they, on their own volition, introduced IPs that were badly designed, e.g. as-charged plans, first dollar riders that did away with deductibles and co-payment etc.
• Highlighted how IP providers misinterpreted and misapplied some of the recommendations of the Health Insurance Task Force (HITF) with highly exclusive panels (21% of eligible specialists), opacity in the selection criteria for panel doctors, and only respecting the lower-end of the MOH Fee Benchmarks
• Questioned the sustainability of the entire IP sector; IP insurers were being indirectly and heavily subsidised by the government through this unique phenomenon of “voluntary downgraders”
• Drew attention to the cost control efforts (or the lack thereof) of IP providers – the Statement referred to a Report published by the Singapore Actuarial Society (SAS) that shown IP providers’ management costs and commission costs grew much faster between 2016 and 2019 than gross premiums and gross claims. The SAS Report revealed that only 75% of premiums collected went to payment of claims.

There was intense public and media attention on the IP sector in the wake of the publishing of the SMA Position Statement. Just three weeks after the publishing of the SMA Position Statement, on 14 April 21, MOH announced the formation of the Multilateral Health Insurance Committee (MHIC) which comprised representatives from major stakeholders in the IP sector. According to The Straits Times, the changes that came about: CCRP and increase in doctor panel size were attributable to the recommendations made “by the MHIC which was set up by the Government in April to reshape the private health insurance market”. (“More specialists on IP insurance panels: What this means for you”; 9 Nov 21)

One can reasonably speculate that without the SMA Position Statement, the MHIC would not have been formed so quickly or even formed at all. And without the MHIC, there would have been no recommendations to set up the CCRP or to increase doctor panel size.

So let’s give the 61^st Council of SMA a clap – without them and their Position Statement in March 2021, we may still be stuck in the trenches and facing stonewall after stonewall every time we tried to get a better deal for patients and doctors.

This evening (4 Oct 21) I was forwarded an opinion piece written by The Straits Times Senior Health Correspondent Ms Salma Khalik, “Covid 19: When there’s confusion. it’s tough to pull together against a common enemy”. It was posted on the ST website at about 2240hrs.

The article stated that “The Singapore Medical Association runs an opinion blog called hobbitsma, penned by an anonymous author”.

I guess the “anonymous author” means me.

The article by Ms Khalik makes many noteworthy points which I encourage you to read. However, I just want to make one important clarification. This blog is run by me. The Singapore Medical Association does NOT run this blog. It may choose to republish some of the posts from time to time with my permission, that’s about it.

The confusion may have arisen because of how my life began. I began as an occasional columnist in the SMA News some 20+ years ago. Then I left the SMA News in 2011 but SMA set up a Facebook account for me and long-term readers will remember that before I used WordPress, my posts were long Facebook posts. However in late 2015 , the Facebook account was discontinued and so even the last vestige of link with SMA has been cut and I now blog on the WordPress platform.

For the last 10 years I have been on my own. A “ronin” hobbit of sorts, not in service of any daimyo and answerable to any editor or editorial board. Completely independent.

This fact can be seen in the “First Post” on Facebook, which I reproduce here in full (first published on July 2011): https://wordpress.com/post/hobbitsma.blog/133

Dear Friends and Colleagues

Yes, the SMA Hobbit is back. But on a different forum from the SMA News.

Even an old coot like this hobbit has to keep up with the times and social media simply cannot be ignored.

The social media offers several advantages from an established hardcopy print medium like the SMA News. For one, there is no printing press deadline to meet. The SMA news goes to print every month and this hobbit has strived hard to meet these deadlines and come up with articles with some regularity in the past. There is no such requirement with the social media such as a blog or a post on Facebook. I can post every few days or every few months.

Secondly, hobbit columns in the past in the SMA News have to conform to rough expectations of print space, i.e. about two pages or about 1300 words. With the social media, there is no such expectation. A post can be just several words or a few hundred words or even more than the usual 1300 words.

Thirdly, there is no editing or censorship by the SMA News Editorial Board. What I post on Facebook is entirely my personal business. There are pluses and minuses to this new arrangement. The main plus is that I am not subject to the Editorial Board’s decisions on what to print and what not to print. The minus is that I am entirely on my own here. Don’t get me wrong, I respect the role and responsibility of the SMA News Editorial Board. They are volunteers and they have a job to do. Having said that, that doesn’t mean I necessarily agree with their decisions even though I must respect them when I contribute to SMA News. So when the differences came to a head over a certain article, I exercised my right to retire from the SMA News as a columnist. To be absolutely clear, there were many important reasons that led me to my retirement from the News about half a year back, including the demands of work, family, but the decision of the SMA News Editorial Board not to print a certain article was also a big contributory factor.

Enough of the past, back to the present. Since this is my first long post here, I need to stress that whatever is posted here does NOT represent in any way the official position of the SMA on any issue. The folks in SMA have kindly set up this Facebook account for me to continue my nonsensical and personal ramblings in Cyberspace. I appreciate this opportunity and new forum and I hope you will continue to support me here virtually as you have had in the past in print.

As you are well aware, the Hobbit lives in a mythical parallel universe called Middle Earth. Unless otherwise and specifically stated, events and personalities referred to in this Facebook account are completely fictitious and belong to the realm of utter fantasy. If you do suspect that I am referring to anyone or any event that you think may have occurred on planet Earth (i.e. 3rd Rock from the Sun, and NOT middle-earth), then let me again reassure you your suspicions are totally unfounded and without any basis.

For the avoidance of doubt and to be absolutely clear – all future writings and opinions expressed here on this Facebook account are un-researched, untrue and cannot be substantiated. So read at your own risk, folks.

What Now:- The Undead Phase?

We are now in uncharted territory. We have gone where no human, hobbit, Klingon has gone before.

This hobbit is not even sure what phase we are in anymore. There were terms like Dorscon Orange, circuit breaker, phase 2 and 3, heightened alert, preparatory phase, transition phase etc that were invented by wordsmiths. Apparently, we may be now in the “stabilisation” phase.

I would like to think we may be in the necromantic “undead” phase. We will trudge on. Till when? To where? Nobody really knows.

I remember I had this discussion with a war historian many years back about why Germany lost World War 2. Man for man, equipment-wise, the German army was equal if not better than any other army at the beginning of the war. By 1941, Germany had conquered almost all of Western Europe. Those that were unconquered were allies of Germany or neutral. After the conquest of Western Europe, the Germans were mainly fighting the British (and later the Americans as well) in North Africa.

But they were defeated because they then chose to fight on two fronts in 1941 to 1942 when Hitler chose to invade Russia in the middle of 1941. Having failed to take Moscow in the winter of 1941, they decided to go for the oilfields in Caucasus in South Russia, which wasn’t a bad idea. The original plan was to just destroy the industrial capacity of Stalingrad and to capture the oilfields. But then Adolf Hitler decided that he wanted to occupy Stalingrad as well, which really was sort of a “vanity project”, as the city is named after his arch-nemesis Stalin.

As history showed, the main bulk of the German forces in the Battle of Stalingrad, the 6^th Army, was wiped out in an encirclement by the Russian Army in the winter of 1942.

The German Army never quite recovered from the disaster in Stalingrad and so lost the war in the Eastern front. In the end, they also lost the war in North Africa because too much resources had been devoted and lost in Russia and the African front was hopelessly under-resourced. This led to the allies invading Sicily in 1943 and Normandy in 1944 while the Russians continued to push westwards and recovering all its lost territory. The war in Europe ended in May 1945 when Germany was defeated by the allies sweeping eastwards and the Russians marching westwards into Berlin.

Fighting on two fronts

When it comes to resources, it is really quite a finite zero-sum game, at least in the short run. Testing of asymptomatic cases, even when self-conducted, is not resource-free on the healthcare system. Testing involves the redeployment of resources and which could have been utilised elsewhere.  

This hobbit is not so sure what we are trying to achieve here. We seem to be going to something akin to a heightened alert phase when the number of cases rise. Then when cases drop, we relax a bit. Which in turn will probably lead to a rise in cases again as social interaction increases, and then we reflexively clamp down again.

Two questions need to be asked:

• Are we in an interminable loop of relaxing/50% to work/5 to dine and restricting/WFH/HBL/2 to dine? Even though 82% have been fully vaccinated and another 3% more due to be fully vaccinated?

• What exactly is this country pursuing as an overarching strategy? Are we pursuing a zero-case strategy like China, Taiwan, New Zealand etc? Or are we going for endemicity, i.e. living with the virus exit strategy?

The answer proffered is that we need to stabilise the situation in the hospitals. For one thing, the situation for those in ICU and those that need oxygen seems rather stable. But there are actually more than 1000 patients admitted for Covid-19. Are our admission criteria too lax? By now we should have enough data to know what are the patient profile characteristics that will give a good prognosis and those that we know will not do well later on. This data should be carefully analysed and translated into better clinical practice so that we do not admit excessively and take up too many beds. At present, out of all patients diagnosed, 1.8% require oxygen, 0.2% are in ICU and the rest are either asymptomatic or mildly ill. Given our extensive experience in the last 20 months treating Covid-19 patients, can we extract more efficiency out of the system in terms of hospitalisations of asymptomatic and mildly ill patients?

On one hand, we say we are resolute on opening up and living with the virus. On the other hand, when we test almost everyone under the sun, we seem to be also going for a zero-case disease elimination strategy. As one public health expert put it, it is like asking each and every person caught in a downpour, “Are you wet?”

Another expert put it more starkly, “the pain of transition is made worse by being stuck in applying disease elimination measures to deal with an endemic disease. Much of what is being done in the name of disease prevention is counter-productive”.

Social media groups involving doctors are rife with comments questioning our strategy of testing asymptomatic folks. And many of these folks are respected experts in the medical community – public health physicians, infectious disease specialists etc.  

We may have some of the best healthcare workers (HCWs) in the world. But we are really tired of fighting on two fronts, supporting policies that apparently are aimed at moving towards endemicity and another set of practices that are aimed at disease elimination. Such a schizophrenic approach quickly tires out people both physically and mentally.

The Costs of Abundant Caution

It is easy to say we must do things “out of an abundance of caution”, which is probably one of the most overused phrases in recent times. But this hobbit feels these folks do not adequately address two important facets of a so-called cautious approach (even though 82% of population have been fully vaccinated):

• The economic cost and livelihoods lost, migrant workers’ well-being, children’s need for social interaction, mental health etc.

• While we say we want to protect healthcare and HCWs, some of these policies ignore the fact that many policies make provision of healthcare so much harder: the 2x weekly swabs, stay home orders for HCWs who are well and vaccinated, confusion among the public so that their only recourse are GPs (who are equally confused) and the already excessively crowded A&Es.

Home Recovery: Policy is Implementation

The next issue that has caught the attention of the medical profession is that of our Home Recovery strategy, which has been declared as the “default care management model” for Covid-19 patients. In itself, this strategy is absolutely correct and in-line with our stated strategy of living with the virus. But the implementation was (out of an abundance of euphemism) in a word – suboptimal. Which is rather interesting, because our transiting into endemicity was not a sudden thing. It has been discussed publicly for months. Other countries have also done it; there are both positive and negative examples of this that we can learn from. Yes when the rubber eventually did meet the road, we were found wanting.

The famous World War 2 American general, George S Patton said “Good tactics can save even the worst strategy. Bad tactics will destroy the best strategy”.

Surely, if this was intended to be a “default” model, then small-scale trials could have been run earlier to spot potential problems in communication and implementation? For example, when a new and important software system is introduced in a big company, there is always User-Acceptance Testing (UAT) performed before the system is rolled out, so that teething problems can be identified and ironed-out. Was there any trial or UAT done before our Home Recovery care management model was implemented? A past Head of Civil Service once said “Policy is implementation”. Unfortunately, some folks obviously didn’t read his memo.

New NS Vocation: Patient Buddy

That leads us to the issue of operations planning and implementation. We are now 20 months into having Covid-19 infections on our shores. If there is one thing that appears to be obviously lacking, it is our capability to plan and implement operations on a large scale quickly and well. And each time, the SAF is called in to save our butts. This is troubling to this hobbit. In many other countries, the armed forces are called in to help out in sudden emergencies and disasters, such as earthquakes and typhoons. In Singapore, they are now called in to answer phone calls and be patient buddies after the country has battled the same Covid-19 virus for 20 months. Chew on that.

An insider commented to this hobbit, “It really goes back to the reward system. If the system rewards those that can best write beautiful policy papers, then the system will produce the best policy paper writers and presenters. If the system rewards those that can do the “sai-kang” (literal Hokkien translation – faecal work; i.e. grunt work) best, then the system will produce the best operators”.

As Mr Brown, the “blogfather” recently inferred in a post (“Kim Huat and the somewhat endemic phase”)  – stop dishing out all these complicated flowcharts that most people have difficulty understanding. In fact, this hobbit has some advice for these flowchart exponents – send your beautiful flowcharts to the most junior person in your department, such as the administrative assistant or receptionist. If they understand it, then it is a good flowchart. If these junior or lesser educated folks don’t understand it, it’s a lousy flowchart. Go back and redesign the workflow and flowchart until it is understood by junior staff before it can be allowed to be circulated. Because if they don’t understand it, chances are not many people out there will.

The Magic Number of 143

Going on to the subject of boosters. On 14 Sep 21, GPs were informed by AIC that boosters can be given for those 60 and above if they had received their two doses at least 6 months (or 180 days) ago. On 17 Sep 21, this was revised to 5 months (or 150 days). That’s fine. Then on 24 Sep 21, another (third) email was sent by AIC (on behalf of MOH) to yet again change the criteria to 143 days and if the person had received an SMS from MOH to take their booster shot.

Do the folks who craft and send out such emails in rapid succession think GPs have nothing to do but read their emails and circulars? Why 143 days? Why not 144 or 142? And why must it be accompanied by the SMS invitation? A nice number like 150 days or 5 months is very good. Thank you. Please don’t load us with more bureaucratic instructions that consumes more memory space. I have a small brain with limited memory space. This hobbit would like to suggest that bureaucrats should be given a KPI that states “Have you made HCWs’ life easier with less bureaucracy?” in their annual performance assessments. I think many will fail this KPI miserably.

So very, very sick of it

A GP working in the Queenstown area said it well in his FB post dated 20 Sep 21,

“Every day MOH sends us a bunch of new directives; there’s so much that my free 5gb mailbox is actually almost full! One day they say one thing, one day we read it in the papers before we get informed.

It’s now 5pm and I wanted to go home at 2 and have a nap, instead I’m clearing all the *@# from just now. And I might as well just stay here since we start again at 6 anyway. I am sooooo sick of having to rush to see and jump queue for pts with a cold, and doing all the paperwork involved in swabbing them. I am so sick of having to trace results every night and calling the pts to tell them that it’s negative. Am so sick of having to learn one new thing after another, and reading about new policies which are not clearly thought out, in the newspaper… quarantine yourself, and then after 3 days gradual return to activities. What the heck is a “gradual return”?

So very, very sick of it”.

It is apparent that to this GP, all the many and periodic expressions of appreciation and gratitude by politicians mean little to frontline HCWs like him when the bureaucrats just insensitively shovel out loads of instructions that make no sense or make life unnecessarily complicated. Pleasantries unsupported by action can only do so much.

What We Need Now

What we need now is hope, not the dreary prospect of interminably oscillating between opening up and shutting down activities, when we already have one of the highest vaccination rates in the world.

What we also need now is unity of purpose to rally the people and the HCWs. This in turn requires clarity of thought.

Hope, clarity of thought and unity of purpose. To achieve these three, we have to first settle on a communications message that is consistent, cogent and concise. This message must then be delivered with great conviction. We then have to develop and implement operations that cohere with this message.

If not, we will just be meandering around like undead zombies in search of both disease elimination and endemicity and finding neither.

2021 seems to be flying past even faster than 2020. Before we know it, we are now down to the last one-third of the year. Gone even faster is the immunity protection afforded by vaccination with Covid-19 vaccines. The government has officially announced that those aged 60 or above, living in aged-care institutions or above and those that are moderately or severely immunocompromised should go for their booster shots.

This hobbit is wondering why healthcare workers (HCWs) are omitted in this first batch of booster-eligible people. After all, HCWs are working in high-risk environments and pose a significant risk to the people they care for should breakthrough infections occur. Also, HCWs are the earliest folks to be vaccinated. Many HCWs were vaccinated even before senior citizens at the beginning of this year. This hobbit hopes HCWs will get their booster shots soon.

We now move on to something that is rather confusing to this hobbit. This hobbit must state that the confusion may probably have arisen because this Hobbit is completely untrained and insufficiently informed in matters concerning the law.

An anaesthetist/pain specialist was recently acquitted of molest by the State Courts of Singapore when the prosecution, i.e. Attorney-General Chambers (AGC) withdrew the charges. However the AGC apparently subsequently disagreed with some things that the doctor’s lawyer did or said and then released two press statements in as many days. In both statements, the way in which the molest was alleged to have taken place were described in quite graphic detail, including how the molester touched the victim’s hips, cupped her breasts and how high the arms of the victim were raised. Both statements strongly suggested that the AGC believed the victim/complainant did not lie.

And yet, the charges were withdrawn, because apparently there were inconsistencies in the evidence garnered from various sources and that from the AGC’s perspective, the high threshold necessary to secure a conviction could not be reached.

Let us first view this from the victim’s perspective. If the molestation did take place, then, we could well have an honest, molest victim out there whose case has been dropped by the AGC due to technical points of the law that few lay people would really understand. This would be a double blow, tragedy upon tragedy for the victim. One cannot imagine the mental devastation that this person has to go through, first to be molested, and then to have the case withdrawn by the public prosecutor because of legal technicalities. There is no closure, and there will probably be life-long and deep emotional scars in this victim’s psyche. It would not be surprising if she would need long-term professional psychological support. My heart goes out to her if she was indeed molested and yet her case was dropped, especially when (according to AGC) there is no evidence to show she lied.

On the other hand, if the accused was innocent and accordingly acquitted, this hobbit can imagine that the first thing the accused wants is to get on with his life, especially when he and his family had in the preceding four years suffered so much indignity and emotional upheaval. Yet, he now sees press statements describing his alleged molestation in detail being made because of some dispute between the AGC and his lawyer. At the emotional level, there is probably no closure for him as well, even though he has been acquitted.

They say the truth shall set you free but frankly, to this legally-ignorant and legally-untrained hobbit, both of the above scenarios come off as rather confusing if not unsatisfying. 

Let’s finally move on to some good news.

The latest SMC Annual Report was released to the profession on 30 Aug 2021. It is a fine document with purported efficacy against insomnia and/or constipation. Anecdotal experience also suggests that reading the case reports of SMC Disciplinary Tribunal outcomes can suffuse the reader with a surreal sense of misplaced schadenfreude.

Fear not, this Hobbit will summarise the Report so that you can have more time during the Pandemic to purse your Covid-related hobbies, such as and baking sourdough and pottery (i.e. baking mud).

First the good news. The number of complaints lodged with the SMC has plunged. While many may ascribe this to Covid-19, the fact is the numbers have been steadily falling since 2016. The last year merely accelerated this trend. The numbers don’t lie:

Year	Number
2016	242
2017	206
2018	200
2019	173
2020	118

This decline in absolute numbers, more than half, is made all the more remarkable when you consider that the number of doctors has increased significantly over the same period (from 13478 to 15430, an increase of 1952 doctors or 14.5%). The complaints rate has declined from 18.0 per 1000 doctors in 2016 to 7.6 per 1000 in 2020.

Somehow, this hobbit doesn’t think the mainstream media will report this very encouraging trend.

From 2018 to 2020, the five commonest categories of complaints were (in order of descending number of complaints)

• Rudeness/Attitude/ Communication Issues
• Unnecessary/Inappropriate Treatment
• Professional Negligence/Incompetence
• Misdiagnosis
• Consent-Related Issues

2020 also marks the year that the number of doctors exceeded 15,000 for the first time in Singapore. About one-third of these work in the private sector and about 39% are specialists.

Over the last five years, it is noteworthy that the number of new provisional registrations (i.e. housemen) have risen from the low 500s to almost 600 a year. About 150 are foreign graduates while the remainder come from the three local medical schools.

For the specialists, it is interesting to note that the five fastest-growing specialties from 2016 to 2020 in terms of percentage growth were:

Specialty	Percentage Increase
Emergency Medicine	43.6
Geriatric Medicine	41.9
Orthopaedics	37.6
Rehab Medicine	30.0
Urology	29.9

The five fastest growing specialties in terms of absolute numbers for the same period are:

Specialty	Increase In Number
Orthopaedics	82
Paediatrics	76
Anaesthesia	73
Diagnostic Radiology	71
Emergency Medicine/General Surgery	Both specialties 68

Looking at these numbers, one must really ask – is the growth in both percentage and absolute number of doctors and specialists sustainable? While we are in the middle of the Pandemic, we certainly want as many doctors as can get our hands on. But when life settles down in a post-Covid world, can we keep up with this growth rate?

In 2020, the number of doctors who did not renew their practising certificates was 81. The nett increase in doctors was 554 for 2020, 542 for 2019 and 390 in 2018. It remains to be seen if the recent cutback in the number of medical schools recognised by SMC will have an appreciable effect on the number of foreign trained doctors returning or coming back to work in Singapore in the coming years. But if the current trends continue, we are talking about a nett increase of a thousand doctors every two to three years.

Why do some people turn to a life of crime? Or at the very least, why do some people live their lives skirting and flirting with the edges of the law?

There could be many reasons, but they probably fall broadly into these three mutually non-exclusive categories

1. Times are very bad and the person turns to crime to survive. That’s why crime rates go up when unemployment rates go up.
2. The person has a pathologically criminal mind and he loves breaking the law, much like what you see in the villains that Batman battles – the folks found in Arkham Asylum like The Joker, Penguin, Two-face etc
3. The person desires to have extraordinary or supernormal profits or pay-cheques that normal business and employment activities cannot match. These people are usually motivated by greed, and their greed overcomes their fear of the law or whatever social stigmata that comes with the running of such (legal) “shady” activities

Obviously, many of these infamous KTV outlets are operated by people belonging to the above third category. These outlets are usually called KTV clubs, bars or lounges. There are also many “family” KTV outlets which are indeed bright and wholesome (which this Hobbit sympathises with – they should indeed be statutorily classified differently from KTV clubs). But those pre-Covid KTV clubs that come with hostesses are obviously not without social stigma, yet they exist because there is demand for them and there are people willing to run these businesses because the profits and margins are very attractive.

Taking this into consideration, this hobbit cannot help but wonder – what makes some people think that by just giving them Food and Beverage (F&B) licenses, these KTV club and lounge operators will suddenly be willing to pivot to a life in the slow lane of humdrum F&B normalcy? Especially when many of these outlets don’t even have commercial kitchens. And why would anyone go to these kitchen-less F&B outlets for the food? Couldn’t they get food delivery to deliver the food to their homes instead?

In addition, it was reported in The Straits Times on 22 July 2021 that “Only 18 ex-nightlife outlets (were) given support packages to switch to F&B” by Enterprise Singapore (ESG). It was reported that 400+ such nightlife establishments pivoted to the F&B industry and yet only 18 received these support packages. This would imply at least two things – the grant was exceedingly hard to get, or that the vast majority of the 400+ outlets did not apply for the package. If the latter is true, the next question that needs to be asked is why would people not want the grant? Take the example of couples who buy a property near their parents and qualify for a government housing grant. This hobbit has never heard of anyone who would not take this grant. People who have nothing to hide will take grants if they can qualify for them. On the other hand……

To this hobbit, this episode of the KTV cluster really shows a lack of understanding of the imperfect human condition and what drives people to do what they do. And yes, it would have been quite hilarious, if not for the serious public health consequences that had arisen from it.

It’s gotten so bizarre that on 25 July 2021 (“Group wants tougher penalties for errant nightline operators”), The Straits Times (ST) reported that “the Singapore Nightlife Business Association (SNBA) also recommended that the 400 nightlife establishments that switched to the food and beverage sector last October come under police supervision”.

This is the first time in a long time in super-safe Singapore that anyone or any organisation has volunteered to come under police supervision. The only folks we run towards here, regardless of race, language or religion, are the parking ticket aunties and uncles who are about to issue a parking ticket to your vehicle. We usually run away from police supervision, not towards it.

OK, so much for the light-hearted stuff. We move on to something more serious and saddening.

On 17 July 21, a letter to the Forum of The Straits Times by a Ms Denise Ho said that her hospitalisation insurance claim for stage 2 breast cancer treatment and claim for critical illness payout were rejected on the grounds that she had failed to report she had vertigo and asthma. These diagnoses were purportedly made after she made visits to a GP for dizziness and cough.

On 26 Jul 21, the Life Insurance Association (LIA) responded by giving by what can be described as a legally correct and general answer. The reply did not comment specifically on the case at hand, but gave the general principle that “in order to reject a claim or invalidate a policy, life insurance companies are responsible for proving that the non-disclosure of the health condition to a question asked in the application form is material to the underwriting outcome…”

LIA also said a person could seek redress with the Financial Industry Disputes Resolution Centre (FIDREC), and finally an aggrieved person can also explore legal action.

On 29 Jul 21, a letter from Mr Chia Boon Teck to the same ST Forum revealed important information. Apparently FIDREC does not allow for involvement by lawyers and “has a claims cap of only $100,000”. So for higher claims, the policyholder has to get legal help, which Mr Chia rightly pointed out, “victims in such scenarios would hardly have any money for their medical treatment, let alone for legal expenses”. Ouch.

Now the LIA reply took pains to say it “is not in a position to comment on any assessments by any specific insurer”, this hobbit is not bound by such self-imposed and convenient rhetorical handcuffs and mufflers of the LIA.

Interestingly, up till now, the relevant regulatory authorities have also kept silent on this matter.

Let’s now really examine the case at hand – breast cancer with a possible history of vertigo and asthma.

Anyone who is medically trained will wonder what has vertigo and asthma got to do with breast cancer. But according to the reply by LIA, the key words are “underwriting outcome”, which means anything that would have altered the insurance policy’s terms, such as loading of insurance premiums or limitation of coverage may allow the insurance company to “reject a claim or invalidate a policy”. This is evidenced by what LIA’s stated condition: – “the terms of the policy would have been different from the terms that were actually offered and issued”.

So while vertigo and asthma have got nothing to do with breast cancer, the fact that these conditions may lead to different terms of the policy from the terms that were actually offered and issued already entitles and justifies an insurance company’s action to deny a claim for breast cancer.

To this hobbit, this is the legally correct but amoral world that policyholders and healthcare providers have to contend with when we deal with insurance companies. It is effectively heaping misery upon misery on a sick person. It is bad enough to have cancer, but the policyholder has to now also contend with the shock and dismay of knowing the hospitalisation insurance policy is not providing coverage because of a technical breach of a contract and face the terrible consequences of this reality.

As a wise dwarven lord told me once, “Always look for the money trail”. On 2 Aug 21, Business Times (“Claims management measures help boost Integrated Shield 2020 results”) reported that Integrated Shield Plans (IP) insurers performed much better in 2020 than 2019. In fact, in 2019, only two (out of seven) IP insurers were profitable, in 2020, all but two insurers were profitable. In 2019, the seven IP insurers incurred an underwriting loss of $43.11M; in 2020, the same insurers made an underwriting profit of $103.75M, a swing of $146.86M!

The most impressive performance was put in by Great Eastern (GE), which went from losing 57.88M to making a profit of $23.29M, a swing of 81.27M. It also somehow managed to cut its management expenses from $33M to $22M from 2019 to 2020.

But let us briefly return to the KTV club sector again. Many KTV hostesses are poor young foreign women who may be brought here to be exploited as hostesses. That in itself is immoral. But many are also here of their own volition to earn a quick and big buck. In which case, other than the fact that there is a lot of negative stigmatisation, everyone gets what they want – the KTV hostess and operator gets paid by the client and in turn the client gets what he wants – varying degrees of physical (maybe carnal even) and emotional satisfaction.

Contrast this to the insurance industry. This industry is ostensibly here to serve their policyholders. But in so-called serving their policyholders, they have elaborate systems, contracts and processes designed to deny certain policyholders what they have actually paid for and now need. It appears they do so by relying on technicalities that few laymen would understand when they bought the policies. The interesting thing is, these insurance companies’ practices are probably deemed acceptable by the authorities, which is why no relevant regulatory authority has yet commented on the abovementioned series of letters in the ST Forum.

If you asked this hobbit, maybe the insurance industry should be the one that comes under police supervision instead of the nightlife sector.

Life can be legal, and also not fair. Get used to it

Happy 56th National Day